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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444406300
Report Date: 06/12/2019
Date Signed: 06/12/2019 01:05:57 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:HERNANDEZ, LISA & JOSEFACILITY NUMBER:
444406300
ADMINISTRATOR:HERNANDEZ, LISAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 763-7607
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:14CENSUS: 8DATE:
06/12/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lisa HernandezTIME COMPLETED:
01:15 PM
NARRATIVE
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Unannounced random visit made by Mahvash Behbood. Met licensee, Lisa Hernandez. purpose of the visit explained. Present also were 8 day care children, 7 school age and one 2 year old. Days and hours of operation is M through F from 6 AM to 6 PM. Inside and outside of the home inspected. children and staff file reviewed.
There are no bodies of water on the property.
Licensee stated there are no gun at home.
Cleaning supplies stored inaccessible to children.
No fire place in day care area. Fire extinguisher is the correct size. Smoke and carbon monoxide are operational. Licensee states the heater works properly.
No stairs. Toys and play equipment are safe and age appropriate.
Telephone is working and the phone number is still the same. She provided her cell number as (831) 234 8080. Children were supervised during the visit.
Discussed with licensee children are not to be left in parked vehicles.
Backyard is divided by a fence and the right side is accessible to children.
There is emergency information on file for all children in care .
The adults who live in the home are licensee, her husband, 2 adult son, one daughter in law and one infant grand child. All adults have fingerprint clearance.
CPR and First Aid is expired in 2019.
IMS is not provided at this time.
Effect of lead exposure poster was provided to licensee and she agreed to share the information with parents.

Off limits: Garage, all bedrooms, one side yard.



See next page for citation under Title 22.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
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
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: HERNANDEZ, LISA & JOSE
FACILITY NUMBER: 444406300
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2019
Section Cited
HSC
1597.622
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IMMUNIZATION SB792- Co - Licensee doesn't have proof of immunization against Measles, Pertusis and Flu shot. This is potentially dangerous to health and safety of children.
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Must be corrected no later than 06/28/19.
Type B
06/28/2019
Section Cited
HSC
1596.8662(b)
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Health and Safety -
Co-licensee has not completed Training on Madated Child Abuse Reporter.
This is potentially dangerous to health and safety of children.
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Must be corrected no later than 06/28/19.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2