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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412525
Report Date: 05/23/2022
Date Signed: 05/23/2022 11:28:32 AM


Document Has Been Signed on 05/23/2022 11:28 AM - It Cannot Be Edited

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: 0DATE:
05/23/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Evelia MadrigalTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Deanna Villagrana and Licensing Program Manager (LPM) Mary Segura conducted a scheduled informal office meeting at the San Jose Regional Office with Licensee Evelia Madrigal to discuss citations issued on 04/28/2022.

LPA observed a child sleeping in a crib with a barricade attached to the crib. The child is old enough to sleep on a cot or mat and was being confined in the crib to sleep. LPA observed an infant asleep in a swing. Licensee stated she did not have a Safe Sleep Log available for review. LPM Mary Segura discussed deficiencies cited during visit that were a repeat violation from report dated 01/31/2000. Licensee does not have a permit for the bathroom that was built outside. Licensee has agreed to tear it down by June 3, 2022 and understands that children cannot use this restroom.

The San Jose Child Care Regional office will make a referral to the Resource and Referral Agency that covers Gilroy area to inquire about training about children's personal rights and safe sleep for the licensee and her helper. Once that is established, the licensee will be given a timeline to complete the trainings.

LPM Mary Segura, explained that if there are continued serious deficiencies cited against the facility including but not limited to citations for Personal Rights and Infant Safe Sleep, the license may be referred to legal for possible administrative action, which could include revocation of the facility license. The facility will be monitored more frequently to ensure that the facility is maintaining compliance with Title 22 regulations. Licensee was provided a copy of the Family Child Care Regulations in Spanish.

LPM Mary Segura discussed the requirements of AB 633 with Evelia Madrigal and provided her with the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and she understands the requirements.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
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
VISIT DATE: 05/23/2022
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Copies of this report must be provided to parents/guardians of children currently in care at this Facility and to parents/guardians of children newly enrolled at this Facility during the next 12 months.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2