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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414612
Report Date: 09/27/2019
Date Signed: 09/27/2019 03:18:23 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:CHAVEZ, JENNYFACILITY NUMBER:
434414612
ADMINISTRATOR:CHAVEZ, JENNYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 899-2885
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:14CENSUS: 4DATE:
09/27/2019
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jenny ChavezTIME COMPLETED:
02:15 PM
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LPA Janet Tse met with licensee Jenny Chavez for a case management inspection today. The purpose of today's visit is to ensure that facility is adhering to the Compliance Plan that facility agreed to implement during the Informal Meeting held at the San Jose Child Care District Office on 03/14/2019. LPA explained the nature of today's visit to Licensee. LPA observed four children including two infants with Licensee in the home. Present in the home was also Licensee's adult son.

LPA observed the last fire and disaster drill, which is to be completed at least once every six months, was practiced on 09/03/2019. LPA reviewed four children's files. LPA observed the LIC 9224 Acknowledgement of Receipt of Licensing Reports for 03/14/2019 and 02/08/2019 with parents' signatures in each child's file. LPA also observed the LIC 995B Addendum to Notification of Parents' Rights regarding removal/exclusion of an individual with parents' signatures in each child's file.

LPA observed the home is clean and orderly with ventilation for the safety and comfort of the children. LPA observed items dangerous to the health and safety of the children were stored inaccessible to children. Children were supervised during the visit.

No deficiency was cited. 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: 09/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2019
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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