444415704-4-7-2025-07-CC-ALUZ-DFHT64-20250407142633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444415704
Report Date: 04/07/2025
Date Signed: 04/07/2025 02:27:15 PM

Document Has Been Signed on 04/07/2025 02:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	PINEDA, GRISELDA		FACILITY NUMBER:	444415704
ADMINISTRATOR/ DIRECTOR:	PINEDA, GRISELDA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 331-1797
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 6	DATE:	04/07/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:05 AM
MET WITH:	Meerabai Clark and Sergio Pineda		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 10:05AM, Licensing Program Analyst (LPA) Angela Luz met with Facility Representatives Sergio Pineda and Meera Bai Clark to conduct an unannounced annual RANDOM inspection. Present for this inspection were six (6) preschool aged children and 1 minor assistant. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from Monday-Friday 8:30AM-5PM. Licensee was not present tor today’s inspection. They are expected to return home tonight. Facility: The ON LIMIT AREAS are living room, bedroom 2, childcare bathroom, rear porch, play yard, and studio. The living room is used as a walkway to get to bedroom 2. The hallway to the backyard is used as a walkway for the bathroom. The OFF LIMIT AREAS are bedrooms 1 and 3, kitchen, garage, storage shed in backyard, and entire second floor. Off limit areas are inaccessible by closed and/or locked doors and visual supervision. Staircases are barricaded to prevent access by children in care. The home is neat and clean with heating and ventilation for safety and comfort. The ISOLATION AREA is bedroom 2. The outdoor play area is free from defects or dangerous conditions and is fully fenced. There is a swing structure with a wide base and hay to cushion the swing area from falls. There have been no changes from the areas previously identified as OFF LIMITS or alterations to existing building or grounds. There are no bodies of water. LPA observed various cleaning products around facility and reminded facility representatives that all hazardous materials and toxins should be kept out of the reach of children. The home has a fully charged 3A40BC fire extinguisher that was last serviced on 4/5/24, working smoke detector, working carbon monoxide detector, and working telephone. LPA reminded that fire extinguishers should be serviced once a year. Facility representative Sergio states that there are firearms in the home. LPA observed firearms stored properly and securely in an off limit area of the home. *Page 1 of 4*

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

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 12

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 12

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PINEDA, GRISELDA	FACILITY NUMBER: 444415704
	VISIT DATE: 04/07/2025

NARRATIVE

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Care and Supervision: There are ample age-appropriate toys that appear to be safe and in good condition. Facility representative Meera Bai uses redirection and talking with the child as forms of discipline. Facility representative understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, interference with eating, intimidation, or other actions of a punitive nature. Children are treated with dignity, receive safe, healthful, and comfortable accommodations.

Records: Facility representative Meera Bai provided LPA with records to review. LPA reviewed two (2) staff files (S1 and S2) for the following records: Employee rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunization records, and required training. S1 is missing CPR/First Aid and Mandated Reporter documentation. Facility representative was reminded Mandated Reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. S2 is missing proof of negative TB test.

A copy of the licensee’s immunization is on file. The Licensee conducts and documents fire and disaster drills every six months, last drill was in December 2024. LPA reminded facility representative Meera Bai that fire and disaster drills should be recorded with the exact date the drill is conducted. Facility representatives could not locate a copy of the facility roster. Licensee does not carry liability insurance and Affidavit Regarding Liability Insurance (LIC 282) were found in children’s files. Entrance checklist for Family Child Care Home was provided and facility representative Meera Bai was reminded of documents to be posted in a prominent, publicly accessible area of the facility.

LPA reviewed six (6) children files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization records. 3 children’s files were missing immunization records. 1 file was missing parent’s rights and a signed copy of LIC 282. 6 of 6 children's files were missing LIC 627.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
***Page 2 of 4***

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

Page: 3 of 12

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PINEDA, GRISELDA	FACILITY NUMBER: 444415704
	VISIT DATE: 04/07/2025

NARRATIVE

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Facility representative was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the facility representative, Meera Bai Clark, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Megan's Law was checked on 3/26/25.

***Page 3 of 4***

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

Page: 4 of 12

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PINEDA, GRISELDA	FACILITY NUMBER: 444415704
	VISIT DATE: 04/07/2025

NARRATIVE

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During today's inspection, 7 Type B deficiencies are issued on attached page 809-D.

Licensee CPR/First Aid certification missing
Licensee Mandated Reporter certification missing
6 of 6 children missing LIC 627
3 out of 6 children missing immunization records
1 child missing parent's rights receipt
1 child missing LIC 282
1 staff (S2) missing proof of negative TB test

1 advisory note is issued.

Licensee shall be present during 80% of daycare operating hours per day

Appeal rights were provided.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Facility Representative, Meera Bai Clark.

***Page 4 of 4***

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

Page: 5 of 12

Document Has Been Signed on 04/07/2025 02:27 PM - It Cannot Be Edited

Created By: Angela Luz On 04/07/2025 at 01:33 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PINEDA, GRISELDA	FACILITY NUMBER: 444415704
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(c)

Administration of Child Day Care Licensing

(c) Current proof of completion for each licensed child day care provider or applicant for that license, administrator, and employee of a licensed child day care facility shall be submitted to the department upon inspection of the child day care or upon request by the department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of Mandated Reporter training, the licensee did not comply with the section cited above in 1 out of 2 staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/07/2025
	Plan of Correction
1 2 3 4	By Plan of correction due date 5/7/25 Licensee will submit proof of S1 Mandated Reporter certificate.

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of required immunizations, the licensee did not comply with the section cited above in 1 out of 2 staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/07/2025
	Plan of Correction
1 2 3 4	By plan of correction due date 5/7/25 Licensee will submit proof of S2 negative TB test.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:

	Angela Luz
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

Page: 6 of 12

Document Has Been Signed on 04/07/2025 02:27 PM - It Cannot Be Edited

Created By: Angela Luz On 04/07/2025 at 01:33 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PINEDA, GRISELDA	FACILITY NUMBER: 444415704
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of CPR/First Aid certifications, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/07/2025
	Plan of Correction
1 2 3 4	By plan of correction due date 5/7/25 Licensee will submit proof of current CPR/First Aid certification for S1.

Type B

Section Cited

CCR

102418(a)

Immunizations

(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 6 children's files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/07/2025
	Plan of Correction
1 2 3 4	By plan of correction due date 5/7/25 Licensee will submit immunization records for C2, C4, and C5.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:

	Angela Luz
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

Page: 7 of 12

Document Has Been Signed on 04/07/2025 02:27 PM - It Cannot Be Edited

Created By: Angela Luz On 04/07/2025 at 01:33 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PINEDA, GRISELDA	FACILITY NUMBER: 444415704
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(8)

Operation of A Family Child Care Home

(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/07/2025
	Plan of Correction
1 2 3 4	By plan of correction due date 5/7/25 Licensee will submit proof of current facility roster.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:

	Angela Luz
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

Page: 8 of 12

Document Has Been Signed on 04/07/2025 02:27 PM - It Cannot Be Edited

Created By: Angela Luz On 04/07/2025 at 01:33 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PINEDA, GRISELDA	FACILITY NUMBER: 444415704
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 6 children's records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/07/2025
	Plan of Correction
1 2 3 4	By plan of correction due date 5/7/25 Licensee will submit proof of parent's rights reciept for C3.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:

	Angela Luz
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

Page: 9 of 12

Document Has Been Signed on 04/07/2025 02:27 PM - It Cannot Be Edited

Created By: Angela Luz On 04/07/2025 at 01:33 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PINEDA, GRISELDA	FACILITY NUMBER: 444415704
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(m)(3)

Operation of A Family Child Care Home

(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1out of 6 children's records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/07/2025
	Plan of Correction
1 2 3 4	By plan of correction due date 5/7/25 Licensee will submit proof of completed LIC 282 for C3.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:

	Angela Luz
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

Page: 10 of 12

Document Has Been Signed on 04/07/2025 02:27 PM - It Cannot Be Edited

Created By: Angela Luz On 04/07/2025 at 02:08 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PINEDA, GRISELDA	FACILITY NUMBER: 444415704
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102421(a)

Child's Records

(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 6 out of 6 children's records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/07/2025
	Plan of Correction
1 2 3 4	By plan of correction due date 5/7/25 Licensee will submit proof of LIC 627 for all enrolled children.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:

	Angela Luz
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

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