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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416049
Report Date: 04/08/2022
Date Signed: 05/04/2022 09:01:03 AM


Document Has Been Signed on 05/04/2022 09:01 AM - 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:BUGARIN, SANDRAFACILITY NUMBER:
434416049
ADMINISTRATOR:SANDRA BUGARINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 685-7090
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:14CENSUS: 5DATE:
04/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sandra BugarinTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee, Sandra Bugarin for a case management inspection. LPA observed Licensee's assistant, Jaqueline Escobar and 5 day care children (4 infants and 1 pre-school age child, age 2).

On April 5, 2022 Licensee reported an unusual incident report where she stated that a neighbor filed a complaint against her for noise level. LPA Berumen asked for the names of children present on April 5, 2022. Licensee was caring for 5 infants and 1 preschool child. For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall twelve children, no more than four of whom may be infants; or more than twelve and up to fourteen children only if the criteria in section 1597.465 of the heath and safety code are met.

LPA Elizabeth Berumen informed licensee, Sandra Bugarin that this report dated 04/08/2022 document(s) 1 Type A citation 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.

NOTICE OF SITE VISIT SHALL BE POSTED ALONG SIDE REPORT AND TYPE A DEFICIENCY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/04/2022 09:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: BUGARIN, SANDRA
FACILITY NUMBER: 434416049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2022
Section Cited

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STAFFING RATIO AND CAPACITY. The maximum number of children for whom care may be provided at any one time when there is an assistant provider shall be either: (1) 12 children, no more than 4 of whom may be infants; or (2) More than 12 and up to 14 children only if no more than 3 are infants, and at least 1 child is enrolled in school, and 1 child is at least 6 years old.
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This requirement was not met as evidenced by:
Per LPA's review of records, there was a total of 5 infants and 1 preschooler in care on April 5, 2022. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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A copy of this Licensing Report must be given to each existing parent and to the parent of children who are enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and be kept in each child's file.

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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.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
LIC809 (FAS) - (06/04)
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