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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270767130
Report Date: 12/04/2023
Date Signed: 12/04/2023 12:40:57 PM

Document Has Been Signed on 12/04/2023 12:40 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ROSE, LAURANNEFACILITY NUMBER:
270767130
ADMINISTRATOR:ROSE, LAURANNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 649-3707
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 5DATE:
12/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Rose Lauranne TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Elizabeth Larios conducted an unannounced case management during another visit and met with Lauranne Rose, Licensee. LPA observed two infant, third toddler children, and Licensee's spouse, William (Bill) Rose during today's inspection. LPA observed upon arrival that infant (C1) & (C2) were napping in a swing and a infant play yard. LPA observed that both infants (C1) & (C2) had a blanket on, while in the swing and inside the infant play yard. LPA advised Licensee that as per Title 22- 102425(b) Infant Safe Sleep regulations, cribs or play yards shall be free from all loose articles and objects. Licensee immediately removed the blankets from the infant in the swing and the play yard. Licensee placed infant (C1) in play yard to sleep. Licensee provided LPA with Child Care Roster. Licensee was provided the following forms and regulations for guidance during today's inspection:

LIC311D Forms/Records to Keep in your Family Child Care Home
LIC9227 Individual Infant Sleeping Plan
Title 22 Infant Safe Sleep

Deficiency was cited, appeal rights were given to Licensee, See (809-D). Exit interview was conducted with Lorena Hernandez, Licensee.

A Notice of Site Visit was issued and must be posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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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Document Has Been Signed on 12/04/2023 12:40 PM - It Cannot Be Edited


Created By: Elizabeth Larios On 12/04/2023 at 11:31 AM
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: ROSE, LAURANNE
FACILITY NUMBER: 270767130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2023
Section Cited
CCR
102425(b)

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102425 Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.
This requirement was not met as evidenced by:
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Licensee immediately removed the blanket from the infant (C1) in the swing and infant (C2) inside the infant play yard. Licensee will review Infant Safe
Sleep Regulations and submit a statement of understanding regarding ensuring cribs or play yards shall be free from loose articles at all times.
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Based on observation, Licensee did not comply with the section cited above. LPA observed infant (C1) in a swing with a blanket and infant (C2) with a blanket in play yard which posed a potential health, safety or personal rights risk to persons in care.
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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:Joel Segura
LICENSING EVALUATOR NAME:Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023


LIC809 (FAS) - (06/04)
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