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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414303
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:27:07 PM

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:LECHUGA, ESTHERFACILITY NUMBER:
434414303
ADMINISTRATOR:LECHUGA, ESTHERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 706-8930
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:13CENSUS: 2DATE:
06/23/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Esther LechugaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management- Legal/Non-compliance inspection. LPA met with Licensee Esther Lechuga and explained the reason for the inspection. The purpose of this inspection is Licensee came into the San Jose Regional Office for an Informal Meeting on 02/10/2020 due to children's file. Present during today's inspection were Licensee, her mom, her brother, and 2 children; whom one was infant age. All adults present have cleared fingerprints.

During today's inspection, LPA reviewed 2 children's files. LPA observed that C-1 had immunization records in their file, but did not have other required forms in file. LPA discussed with Licensee the forms required for children.

C-1's parent filled out paperwork during today's inspection. C-1 is still missing LIC 282: Affidavit Regarding Liability Insurance. Licensee stated that she will have C-1's parent fill it out and send a copy to Licensing by 07/02/2021.

LPA observed that there were baby bouncers in the home. LPA discussed with Licensee that baby bouncers are not permitted in the home. Licensee stated that she will remove baby bouncers.

As a result of this inspection, a Type B deficiency was cited. An exit interview was conducted where this report, citation, plan of correction, and appeal rights were discussed and provided to Licensee. A Notice of Site Visit has been issued and must be posted for 30 consecutive days.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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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: LECHUGA, ESTHER
FACILITY NUMBER: 434414303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2021
Section Cited

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CHILD'S RECORDS - The licensee shall maintain, in each child’s record...the signed and dated notice form LIC 995A: Parents Rights Notice, LIC 700: Identification of Parents...
This requirement is not met as evident by:
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Based on record reviews, C-1 only had immunization record and did not have required forms in their file. This poses a potential risk to the health and safety to the 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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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