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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414529
Report Date: 02/27/2020
Date Signed: 02/27/2020 04:43:53 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:HERNANDEZ, ELSYFACILITY NUMBER:
434414529
ADMINISTRATOR:HERNANDEZ, ELSYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 509-6250
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:14CENSUS: 5DATE:
02/27/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Elsy HernandezTIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Elsy Hernandez for a Plan of Correction visit. Present were licensee and five day care children.

LPA observed a current roster, immunization against pertussis, measles and a note declining influenza vaccination for herself and immunization records for child 6 and 7 of LIC811 dated 02/14/2020. LPA did not receive a plan of correction from licensee stating she understood her capacity. Licensee wrote a statement correcting deficiency during visit. A civil penalty of $1,300 was assessed during visit for failure to correct.

An exit interview was conducted a copy of this report and appeal rights were discussed and let with licensee Elsy Hernandez, whose signature on this form confirm receipt of these documents.

No deficiencies were cited during visit.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
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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