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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274402986
Report Date: 03/20/2024
Date Signed: 03/20/2024 11:21:12 AM

Document Has Been Signed on 03/20/2024 11:21 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SALAZAR, MIROSLAVA, SAUL & MIRSA DE LA ROSAFACILITY NUMBER:
274402986
ADMINISTRATOR:SALAZAR, MIROSLAVA & SAULFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 676-3413
CITY:SALINASSTATE: CAZIP CODE:
93907
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 2DATE:
03/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Miroslava SalazarTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an unannounced case management inspection to the home today. LPA met with Miroslava Salazar. Licensee was providing care to two preschool children. Licensee was unable to provide a current children's roster.

A type B deficiency was cited today.
Failure to comply with the Plan Of Corrections (POC) by the due date on LIC809D shall result in an immediate civil penalty of $100 per day per each deficiency.

Exit interview conducted and report was reviewed in Spanish with the licensee Miroslava Salazar.

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

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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
Document Has Been Signed on 03/20/2024 11:21 AM - It Cannot Be Edited


Created By: Fermin Campos-Jaramillo On 03/20/2024 at 10:52 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: SALAZAR, MIROSLAVA, SAUL & MIRSA DE LA ROSA
FACILITY NUMBER: 274402986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2024
Section Cited
CCR
102417(g)

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8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
This regulation was not met as evidenced by: Licensee did not provide a current children's roster, This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Licensee shall update a children's roster and wil submit a copy to Licensing Program not later than April 3, 2024.

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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:Susy Cervantes
LICENSING EVALUATOR NAME:Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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