434412563-4-17-2024-07-CC-DVIA-D4EVCL-20240417161918

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434412563
Report Date: 04/17/2024
Date Signed: 04/17/2024 04:19:38 PM

Document Has Been Signed on 04/17/2024 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	VERGARA, LAURA		FACILITY NUMBER:	434412563
ADMINISTRATOR:	LAURA VARGARA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 272-2472
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	14	CENSUS: 6	DATE:	04/17/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Laura Vergara		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Laura Vergara for an annual/random visit. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's sister Domitila Vergara who is her assistant and six day care children including two infants. Days and hours of operation are Monday to Saturday, 6:00am to 8:00pm. The adults that reside in the home are licensee, her adult brother, her sister with her husband, adult son, 16 year old daughter and 14 year old son. A review of staff records on 04/04/2024 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Laura Vergara was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA did not observe a fireplace or stairs in the home. LPA observed two infants sleeping in the same play yard with two blankets inside of the play yard and hanging over the play yard. Licensee had to move the door to the room infants were sleeping in to observed infants. The door is of solid wood which licensee cannot see through. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed beauty supplies including shampoos, conditioners, and ointments in bathroom drawers and cabinets, dish soap, AJAX and King Clean under the kitchen sink and car cleaning items in the backyard accessible to children. LPA observed a fully charged 3A40BC fire extinguisher, a working smoke and carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: two bedrooms. There are no bodies of water. Backyard is fenced. Off limits

SUPERVISOR'S NAME: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

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 12

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VERGARA, LAURA	FACILITY NUMBER: 434412563
	VISIT DATE: 04/17/2024

NARRATIVE

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outdoor: two locked storage and detached garage. Licensee states she has two cats that stay outside and are vaccinated plus three birds. LPA observed licensee and her sister have a current CPR and First Aid certification expiring 08/28/2025 and license completed Mandated Reporter training on 05/12/2022. Assistant completed Mandated Reporter training on 01/21/2022.

LPA did not observed a current roster of the children. LPA observed a fire and disaster drill log was last completed on 09/04/2020. LPA reviewed nine children's files. Child 8 and 9 are missing LIC700. Child 3, 4, 5, 8, and 9 are missing LIC995. Child 3, 4, 8, and 9 are missing LIC282. Child 3, 4, 8, and 9 are missing LIC627. Licensee stated she did not have a Safe Sleep log for infants in care. Child 1, 2, 4, and 9 immunization records need to be updated. Licensee states day care is not insured. LPA discussed SB792 Immunization Requirements and observed licensee and assistant have immunization records on file.

Supervision of children was discussed with licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed the safe sleep regulations with licensee Laura Vergara and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee Laura Vergara of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA discussed Zero Tolerance related regulations with licensee Laura Vergara and was advised of the assessment of $500 immediate civil penalty and an ongoing $100 per day per violation continues until the violation(s) is corrected. Incidental Medical services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800)514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

SUPERVISOR'S NAME: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VERGARA, LAURA	FACILITY NUMBER: 434412563
	VISIT DATE: 04/17/2024

NARRATIVE

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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Exit interview conducted and report was reviewed with the licensee Laura Vergara. During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPA Deanna Villagrana informed licensee Laura Vergara that this report dated 04/17/2024 document(s) 5 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Deanna Villagrana informed the licensee Laura Vergara to provide a copy of this licensing report dated 04/17/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/17/2024 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VERGARA, LAURA	FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102417(g)(4)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed beauty supplies including shampoos, conditioners, and ointments in bathroom drawers and cabinets, dish soap, AJAX and King Clean under the kitchen sink and car cleaning items in the backyard accessible to children which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	Licensee removed items during visit. Deficiency cleared today.

Type A

Section Cited

CCR

102425(a)

Infant Safe Sleep

(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed two infants sleeping in the same play yard which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2024
	Plan of Correction
1 2 3 4	Licensee removed one infant and placed in a separate play yard. Licensee will read Safe Sleep regulations and submit a statement stating her and her assistant understand regulations to CCLD by POC date.

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: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

Page: 4 of 12

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VERGARA, LAURA	FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102425(b)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed two blankets in play yard were infants were sleeping which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2024
	Plan of Correction
1 2 3 4	Licensee will read Safe Sleep regulations and submit a statement stating her and her assistant understand regulations to CCLD by POC date.

Type A

Section Cited

CCR

102425(b)(3)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed blankets hanging over play yard of infants sleeping which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2024
	Plan of Correction
1 2 3 4	Licensee removed blankets during visit. Licensee will read Safe Sleep regulations and submit a statement stating her and her assistant understand regulations to CCLD by POC date.

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: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VERGARA, LAURA	FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102425(j)(5)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Licensee had to move the door to the room infants were sleeping in to observed infants which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2024
	Plan of Correction
1 2 3 4	Licensee will read Safe Sleep regulations and submit a statement stating her and her assistant understand regulations to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VERGARA, LAURA	FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA observed a fire and disaster drill log was last completed on 09/04/2020 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Licensee will conduct a fire and disaster drill and submit updated log to CCLD by POC date.

Type B

Section Cited

CCR

102425(j)(5)(A)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. The provider shall be able to visually observe the infant without moving the door. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. The door is of solid wood which licensee cannot see through which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Licensee will read Safe Sleep regulations and submit a statement stating her and her assistant understand regulations to CCLD by POC date.

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: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

Page: 7 of 12

Document Has Been Signed on 04/17/2024 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VERGARA, LAURA	FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Assistant completed Mandated Reporter training on 01/21/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Licensee's assistant will complete Mandated Reporter training and submit updated certificate to CCLD by POC date. Training can be found at www.mandatedreporterca.com.

Type B

Section Cited

CCR

102418(g)(1)

Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Child 1, 2, 4, and 9 immunization records need to be updated which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Licensee will submit updated immunization records for child 1, 2, 4, and 9 to CCLD by POC date.

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: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

Page: 8 of 12

Document Has Been Signed on 04/17/2024 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VERGARA, LAURA	FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102421(b)

Child's Records

(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. Child 8 and 9 are missing LIC700 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Licensee will submit LIC700 for child 8 and 9 to CCLD by POC date.

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Child 3, 4, 8, and 9 are missing LIC627 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Licensee will submit LIC627 for child 3, 4, 8, and 9 to CCLD by POC date.

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: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

Page: 9 of 12

Document Has Been Signed on 04/17/2024 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VERGARA, LAURA	FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(8)

Operation of A Family Child Care Home

(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA did not observed a current roster of the children which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	Licensee completed roster during visit. Deficiency cleared today.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

Page: 10 of 12

Document Has Been Signed on 04/17/2024 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VERGARA, LAURA	FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Child 3, 4, 5, 8, and 9 are missing LIC995 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Licensee will submit LIC995 for child 3, 4, 5, 8, and 9 to CCLD by POC date.

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: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

Page: 11 of 12

Document Has Been Signed on 04/17/2024 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VERGARA, LAURA	FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(m)(3)

Operation of A Family Child Care Home

(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Child 3, 4, 8, and 9 are missing LIC282 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Licensee will submit LIC282 for child 3, 4, 8, and 9 to CCLD by POC date.

Type B

Section Cited

CCR

102425(j)(2)(D)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. Licensee stated she did not have a Safe Sleep log for infants in care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Licensee will begin to keep a Safe Sleep log and submit log beginning 04/18/2024 - 04/26/2024 to CCLD by POC date.

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: Susy Cervantes	TELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

Page: 12 of 12