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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412525
Report Date: 02/21/2020
Date Signed: 02/21/2020 09:36:49 AM

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:MADRIGAL, EVELIAFACILITY NUMBER:
434412525
ADMINISTRATOR:MADRIGAL, EVELIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 310-0298
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 8DATE:
02/21/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Evelia MadrigalTIME COMPLETED:
09:45 AM
NARRATIVE
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LPA Deanna Villagrana met with licensee Evelia Madrigal for an unannounced plan of correction visit. Present were licensee, licensee's assistant Maria Palomares and 8 day care children.

LPA observed children's files and assistant Maria Palomares file were complete. All children who required immunizations were in file. LPA observed roster was complete for children present during visit on 01/31/2020. LPA observed two new children present and were not listed on the roster. This is a repeat violation and a $250 civil penalty was assessed during visit. Licensee's assistant complete roster during visit.

The following Type B deficiency was cited on the attached page (809-D). Appeal rights were provided to the Licensees prior to the conclusion of today's inspection.

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: 02/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2020
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 2
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: MADRIGAL, EVELIA
FACILITY NUMBER: 434412525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2020
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 two new children present and 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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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: 02/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2020
LIC809 (FAS) - (06/04)
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