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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444406177
Report Date: 05/17/2023
Date Signed: 05/17/2023 11:04:35 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/17/2023 11:04 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:MAGDALENO, ESPERANZAFACILITY NUMBER:
444406177
ADMINISTRATOR:MAGDALENO, ESPERANZAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 728-3949
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:14CENSUS: 0DATE:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Esperanza MagdalenoTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee, Esperanza Magdaleno. Esperanza states she hasn't been providing care to children since August 30, 2020 due to health issues.

Licensee is requesting to be placed on inactive status for one year and agrees to comply with all the following conditions:
a. I will not provide child care for which a license is required until my license is reactivated.
b. I will continue to promptly pay the annual license fee. $140 due on or before 07/29/23.
c. I will inform your office of any changes in the above dates prior to re-opening my facility by submitting a new LIC9211 (request for inactive license status).
d. I will be in compliance with all licensing laws and regulations upon re-opening my facility, including but not limited to: ensure all adult staff and residents, including children who turn 18 during the inactive period, have criminal record clearances.
Maintain current CPR and First Aid certifications. Maintaining a current fire extinguisher and functioning smoke alarms.


LPA provided a copy of the Request for Inactive Child Care License Status form (LIC9211) for her to complete. Licensee, Esperanza Magdaleno completed the form during today's visit and request to be inactive from today, 05/17/2023 to 05/17/2024. Licensee understands that an inspection will be conducted prior to her re-opening.
No deficiencies were cited today. A Notice of Site visit was provided and must remain posted for 30 days

Exit interview conducted with Esperanza Magdaleno and copy of report provided.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
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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