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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412563
Report Date: 03/02/2018
Date Signed: 05/08/2019 06:39:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:VERGARA, LAURAFACILITY NUMBER:
434412563
ADMINISTRATOR:LAURA VARGARAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 272-2472
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:14CENSUS: 4DATE:
03/02/2018
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Laura Vergara TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Elizabeth Berumen conducted an Unannounced Plan of Correction Inspection. LPA also provided Laura an electronic copy of annual 3 year visit dated, 02/23/18. LPA was unable to print a report that day due to a consistency check.

Upon arrival, LPA observed 4 day care children (one infant, 3 preschoolers) at the facility and met with Licensee, Laura Vergara. The purpose of today's inspection was to review the facility plan of correction regarding the citations issued on 02/23/18. LPA observed that the facility is equipped with a carbon monoxide detector. LPA observed current roster, 9 completed children's files; including immunization's, Laura practiced a fire disaster drill on 02/27/18. LPA received a written statement from Licensee stating she understands the fingerprinting requirements. The adult present on 02/23/18 lives in Modesto and will not be visiting/helping in the home.
The citations issued on 02/23/18 have been cleared.



No deficiencies have been cited as a result of today's inspection. A Notice of Site Visit has been issued and must remain posted for 30 consecutive days. Exit interview conducted with Licensee, Maria Vergara.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2018
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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