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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274412287
Report Date: 06/18/2024
Date Signed: 06/18/2024 12:23:01 PM

Document Has Been Signed on 06/18/2024 12:23 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:CASTILLO-URENA, ADRIANNAFACILITY NUMBER:
274412287
ADMINISTRATOR/
DIRECTOR:		CASTILLO-URENA, ADRIANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 578-9340
CITY:SOLEDADSTATE: CAZIP CODE:
93960
CAPACITY: 14TOTAL ENROLLED CHILDREN: 15CENSUS: 10DATE:
06/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Adrianna Castillo-UrenaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Jimenez-Villanueva conducted a unannounced Case Management inspection to verify if licensee is operating according with regulations. LPA meet with Adrianna Castillo-Urena and informed the purpose of today's visit. Licensee has in care: two infants, seven toddlers and one schooler. LPA observed her daughter (sixteen years old) was acting as assistant. Later on the visit the assistant arrived.

LPA toured inside and outside of the home. LPA observed no bodies of water. LPA observed the Report and Deficiency Type A, was not posted. LPA observed drill log and the last drill log was conducted on 03/15/2024. LPA observed a full fire extinguisher 2A10BC last served on 05/172024. LPA reviewed a current Children's Roster and observed that there are 15 children enrolled. LPA observed that Licensee has a current 15 minute sleep log for the two infants enrolled.

LPA observed that the Acknowledge of Receipt of Licensing Reports (LIC9224) have not been signed by the parent(s)/legal guardians. Licensee states she forgot to provide properly and collect signatures.

The following type B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Exit interview was conducted with Licensee Adrianna Castillo-Urena.



A notice of Site inspection was printed and licensee was instructed to post it for 30 consecutive days
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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 06/18/2024 12:23 PM - It Cannot Be Edited


Created By: Martha Jimenez-Villanueva On 06/18/2024 at 11:13 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: CASTILLO-URENA, ADRIANNA
FACILITY NUMBER: 274412287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2024
Section Cited
CCR
1596.8595(a)(3)

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Posting licensing report by child care facility or home; duration of posting; civil penalty for failure to comply...(3) Failure to comply with paragraph (1) shall result in an immediate civil penalty of one hundred dollars ($100).
This requirement is not met as evidenced by:
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Licensee will submit proof of posted report and deficiency A was posted by the end of today visit.
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Based on observation and interview, the licensee did not comply with the section cited above by LPA observed the Report and Deficiency Type A, was not posted which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
06/18/2024
Section Cited
CCR1596.8595(c)(1)

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A licensed child day care facility shall provide to the parents or guardians of A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care
This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
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Licensee will submit proof of complete LIC 9224 for each child in care to CCLD by the end of business day of 06/20/2024.
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Based on observation and interview, the licensee did not comply with the section cited above by LPA observed that the Acknowledge of Receipt of Licensing Reports (LIC9224) have not been signed by the parent(s)/legal guardians.
which poses 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:Belinda Devall
LICENSING EVALUATOR NAME:Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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