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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444407145
Report Date: 07/19/2019
Date Signed: 07/19/2019 01:52:51 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:AGUIRRE, IRENEFACILITY NUMBER:
444407145
ADMINISTRATOR:AGUIRRE, IRENEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 421-0321
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:14CENSUS: 8DATE:
07/19/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Irene AguirreTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Zaid Hakim conducted an Unannounced Case Management - Other Inspection at the facility today. Upon arrival, LPA observed eight (8) preschool age children and three (3) staff engaging in daily activities and met with Ms. Irene Aguirre, Licensee. The purpose of the inspection was to respond to the Licensee request to expand on-limit use areas of the home and to clarify a discrepancy with the facility file at the Licensing Office.

The Licensee has been informed that in order to be cleared to use currently off-limit areas of the home, an updated Fire Clearance will be required. LPA toured the areas of the home requested for use. LPA informed the Licensee of the following:

- An Updated Fire Clearance will be required and requested upon receipt of the Fire Safety Inspection Fee
- An Updated Facility Sketch of all on / off limit areas of the home
- All items and furnishings in the requested areas shall be age appropriate and safe and any items potentially dangerous to children shall be locked or inaccessible.

LPA and the Licensee also discussed: Safe Sleep for Infants in Care, Health Effects of Lead in Drinking Water, and Active Shooter Situations.

A Notice of Site Visit has been issued and must remain posted for 30 consecutive days. No Deficiencies have been cited. Exit interview conducted with Ms. Irene Aguirre, Licensee.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Zaid HakimTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
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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