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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434412525
Report Date: 04/27/2020
Date Signed: 04/29/2020 08:11:20 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2020 and conducted by Evaluator Deanna Villagrana
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20200306142702
FACILITY NAME:MADRIGAL, EVELIAFACILITY NUMBER:
434412525
ADMINISTRATOR:MADRIGAL, EVELIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 310-0298
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 7DATE:
04/27/2020
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Evelia MadrigalTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
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9
Day care child sustained unexplained injuries
INVESTIGATION FINDINGS:
1
2
3
4
5
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9
10
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12
13
Licensing Program Analyst (LPA), Deanna Villagrana, conducted a televisit via facetime with Licensee Evelia Madrigal to deliver findings for the above allegation. LPA explained the nature of the televisit to her.

LPA Villagrana conducted interviews, toured the home and obtained copies of pertinent information and photos. Based on LPA's observation, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiency was cited.

A NOTICE OF SITE VISIT WAS MAILED TO LICENSEE AND SHALL BE POSTED FOR 30 DAYS.

This report has been emailed to Licensee and Licensee will reply to email in lieu of a signature.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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