<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415623
Report Date: 11/01/2022
Date Signed: 11/01/2022 02:36:45 PM

Document Has Been Signed on 11/01/2022 02:36 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:LOPEZ, OLGAFACILITY NUMBER:
274415623
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
11/01/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Olga LopezTIME 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
On 11/01/2022 at 1:35 PM, Licensing Program Analyst (LPA) Susy Cervantes, met with an adult, Christina Lopez, LPA explained to adult they were there to conduct a case management to increase licensee's capacity. Adult stated they had been asked by licensee to watch the children since licensee had to step out because of an emergency. Present was adult with 4 children in care: 1 infants and 4 preschool.

At 2:18 PM, licensee arrived with 2 school age children, adult left shortly after. LPA explained to licensee that they will not be conducting the inspection for the increase of capacity.

Type A deficiency was cited during today's visit. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPA Cervantes informed licensee, Olga Lopez, that this report dated 11/01/2022 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Susy Cervantes informed the licensee, to provide a copy of this licensing report dated 11/01/2022 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed in Spanish with the licensee, Olga Lopez. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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 11/01/2022 02:36 PM - It Cannot Be Edited


Created By: Susy Cervantes On 11/01/2022 at 02:05 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: LOPEZ, OLGA
FACILITY NUMBER: 274415623

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2022
Section Cited
CCR
102370(d)(1)

1
2
3
4
5
6
7
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will schedule an appointment for Christina Lopez to get fingerprint cleared and will submit proof of scheduling to the San Jose Regional Office by close of business on November 2, 2022.
8
9
10
11
12
13
14
Based on observation and record review, adult Christina Lopez, has not been fingerprinted and was alone supervising the children. This poses an immediate risk to the health, safety, and personal rights of the children in care.
8
9
10
11
12
13
14
Licensee will then send proof of completion.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Mary Segura
LICENSING EVALUATOR NAME:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2