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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434415899
Report Date: 04/05/2022
Date Signed: 04/05/2022 03:37:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2022 and conducted by Evaluator Deanna Villagrana
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20220228111937
FACILITY NAME:LAZO SAMANIEGO, HERMITA ANAFACILITY NUMBER:
434415899
ADMINISTRATOR:HERMITA ANA LAZO SAMANIEGOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 416-6916
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:14CENSUS: 14DATE:
04/05/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Hermita Ana Lazo SamaniegoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Licensee yells at children in care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Deanna Villagrana and Teodoro Trujillo met with licensee Hermita Ana Lazo Samaniego to deliver findings for above allegation. Present were licensee, licensee's assistants Shirley Rodriguez and Guiselle Ruiz with 14 children including five infants.

Based on interviews which were conducted and pertinent information obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Licensee yells at the children. California Code of Regulations, H&S 1596.80, are being cited on the attached LIC9099D.

LPAs Deanna Villagrana and Teodoro Trujillo informed licensee Hermita Ana Lazo Samaniego that this report dated 04/05/2022 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 07-CC-20220228111937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899
VISIT DATE: 04/05/2022
NARRATIVE
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Also, LPAs Deanna Villagrana informed the licensee Hermita Ana Lazo Samaniego to provide a copy of this licensing report dated 04/05/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 07-CC-20220228111937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2022
Section Cited
CCR
102423(a)(1)
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Each child receiving services from a family child care home shall be accorded dignity in his/her personal relationships with staff, residents and other persons. This requirement was not met as evidenced by
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Licensee understands she must cease yelling at children. Licensee will submit a statement stating she understands children shall be treated with dignity and respect.
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Licensee yells at the children.

This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3