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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414527
Report Date: 07/07/2021
Date Signed: 07/07/2021 12:21:00 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:SALAS, INOCENCIAFACILITY NUMBER:
434414527
ADMINISTRATOR:SALAS, INOCENCIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 685-2422
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY:14CENSUS: 4DATE:
07/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Inocencia SalasTIME COMPLETED:
12:20 PM
NARRATIVE
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LPA Janet Tse met with licensee Inocencia Salas for a Case Management inspection regarding the incident Licensee reported on 06/21/2021 and received by Licensing on 06/24/2021. LPA explained the nature of today's visit to Licensee. There were four children including one infant with Licensee in the home today.

LPA interviewed Licensee regarding the incident. Based on information gathered, there was lack of supervision which resulted a child wandering away.

LPA discussed the requirements of AB633 to Licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Licensee understands the requirements. Upon receipt, Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Deficiency was cited. An immediate civil penalty of $500 for zero tolerance is assessed. Notice of site visit was issued and must be posted with type A deficiency cited for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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: SALAS, INOCENCIA
FACILITY NUMBER: 434414527
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited

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Operation of a Family Child Care Home. The licensee shall be present in the home and shall ensure that children in care are supervised at all times...

This requirement was not met as evidenced by:
There was lack of supervision which resulted
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 a child wandering away.

This poses an immediate risk to the Health, Safety, or Personal Rights to children in care.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.

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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
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