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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410468
Report Date: 02/12/2020
Date Signed: 02/12/2020 04:04:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GAETA, ABELICIAFACILITY NUMBER:
434410468
ADMINISTRATOR:GAETA, ABELICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 842-8076
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 9DATE:
02/12/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Abelicia GaetaTIME COMPLETED:
04:15 PM
NARRATIVE
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LPA Deanna Villagrana met with Licensee Abelicia Gaeta for a unannounced plan of correction visit. Present were licensee, licensee's assistant and 9 day care children.

LPA cleared deficiencies cited on 01/22/2020 including children's files, immunizations and plan of correction. LPA observed LIC9224 in each child's file. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children.

LPA observed child 1 and 2 were not listed on the roster. Licensee stated child 1 and 2 began attending the facility on Monday, February 10, 2020. Child 1 and 2 are missing entire file.

The following type B deficiencies are cited on the attached page (809-D). Appeal rights were provided to the Licensees prior to the conclusion of today's inspection. A civil penalty of $1000 was assessed for repeat violations. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.


Notice of site visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GAETA, ABELICIA
FACILITY NUMBER: 434410468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2020
Section Cited

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102417(g)(8) Operation of a Family Child Care Home. All homes shall have a current roster of the children. This requirement was not met as evidenced by LPA observed child 1 and 2 were not listed on the roster.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
02/19/2020
Section Cited

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102421(a) Childs Records. The licensee shall maintain, in each child’s record, the signed and dated notice form LIC 995A, Parents Rights Notice.
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This requirement was not met as evidenced by Child 1 and 2 are missing entire file. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GAETA, ABELICIA
FACILITY NUMBER: 434410468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2020
Section Cited

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102421(b) Childs Records. The licensee shall maintain, in each child’s record, a copy of the emergency information card required in Section 102417(g) (7).
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This requirement was not met as evidenced by Child 1 and 2 are missing entire file. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
02/19/2020
Section Cited

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An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
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This requirement was not met as evidenced by Child 1 and 2 are missing entire file. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GAETA, ABELICIA
FACILITY NUMBER: 434410468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2020
Section Cited

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Health and Safety Code Section 1596.8595 (c) A licensed child care facility or home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as specified in paragraph (1) of subdivision (a) of Section 1596.893b
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This requirement was not met as evidenced by Child 1 and 2 are missing entire file. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4