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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414527
Report Date: 07/26/2021
Date Signed: 07/26/2021 11:01:24 AM

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: 0DATE:
07/26/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Salas InocenciaTIME COMPLETED:
11:05 AM
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Licensing Program Manager Mary Segura and Licensing Program Analyst Janet Tse met with licensee Salas Inocencia for the purpose of conducting an Informal Meeting to discuss the following issue of deficiencies.

Licensee reported an unusual incident occurred in late June regarding a child, who was alone without supervision in the backyard, left the child care home and went into a neighbor's home without Licensee's knowledge. The child was later returned to Licensee by a police officer while Licensee was looking for the child on the street in front of her home.

LPA conducted a Case Management inspection for the reported incident and issued the following citation on 07/07/2021:

Section 102417(a) 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... There was lack of supervision resulting a child wandering away.

Licensee submitted a written plan of correction to Licensing on 07/08/2021.
Facility Evaluation Report dated 07/26/2021 to be continued on next page: - Pg 1 of 2 -
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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: SALAS, INOCENCIA
FACILITY NUMBER: 434414527
VISIT DATE: 07/26/2021
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Facility Evaluation Report dated 07/26/2021 to be continued from previous page (Pg 1):
Licensees agreed to do the following in order to bring the facility into compliance:

1) To ensure and to coordinate with assistant so children are provided
supervision at all times.
2) To closely observe and supervise children to prevent similar incident
happening again.

The facility will be monitored more frequently to ensure that facility is in compliance with the regulations. LPM advised licensees that the department takes this type of citations very seriously. Also advised that if there are continuous deficiencies cited for the above issue, this license will be referred to our Legal Department for possible administrative action against the license, which could include revocation.

LPM discussed the requirements of AB 633 to Licensee and provided her the fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224), and Licensee stated she understands the requirements.
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SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC809 (FAS) - (06/04)
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