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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415847
Report Date: 08/12/2022
Date Signed: 08/12/2022 03:18:59 PM


Document Has Been Signed on 08/12/2022 03:18 PM - It Cannot Be Edited

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:AVALOS, MARIA DEL CARMEN & CERNA, JUANAFACILITY NUMBER:
434415847
ADMINISTRATOR:AVALOS, MARIA DEL CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 346-2243
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 11DATE:
08/12/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Maria Del Carmen Avalos and Juana CernaTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management- Legal/Non-compliance inspection. LPA met with Licensees Maria Del Carmen and Licensee Juana Cerna and explained the reason for the inspection. The purpose of this inspection is the San Jose Regional Office conducted a virtual informal meeting on 11/08/2021 due to staffing ratio and capacity.

During today's inspection, LPA observed there were 11 children, whom four were infant age. Facility was within ratio during today's inspection. A copy of the facility roster was obtained.

Exit interview conducted and report was reviewed with the Licensees Maria Del Carmen Avalos. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2022
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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