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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414612
Report Date: 01/24/2020
Date Signed: 01/24/2020 11:09:33 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:CHAVEZ, JENNYFACILITY NUMBER:
434414612
ADMINISTRATOR:CHAVEZ, JENNYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 439-1747
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:14CENSUS: 2DATE:
01/24/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jenny ChavezTIME COMPLETED:
11:15 AM
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LPA Janet Tse met with licensee Jenny Chavez for a Plan of Corrections inspection. LPA explained the nature of today's visit to Licensee. LPA observed two infants with Licensee in the home today.

LPA did not receive the plan of corrections for the deficiency cited on 12/11/2019. Licensee showed LPA records of doctor's appointment on 01/30/2020 and another one on 02/28/2020. Licensee stated that due to her medical insurance, she could not obtain an appointment sooner.

No deficiency was cited. An advisory note was issued. Notice of site visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2020
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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