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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 354416067
Report Date: 12/14/2022
Date Signed: 12/14/2022 11:42:23 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2022 and conducted by Evaluator Deanna Villagrana
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20221213082756
FACILITY NAME:LOPEZ, VANESSAFACILITY NUMBER:
354416067
ADMINISTRATOR:VANESSA LOPEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 537-5730
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:14CENSUS: 3DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Vanessa LopezTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Licensee does not ensure that personnel records are properly maintained
Licensee does not ensure that childrens records are properly maintained
INVESTIGATION FINDINGS:
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Licesensing Program Analyst (LPA) Deanna Villagrana met with licensee Vanessa Lopez to open complaint for above allegations. Present were licensee, licensee's 12 year old son and three day care children.

LPA reviewed 11 children's files and one staff file. Child 3 and 4 did not have immunization records on file. Staff Roxanna Davila did not have LIC9052, LIC508, LIC9108 and immunization against pertussis, measles and influenza on file. Based on observation and interview, which was conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Health and Safety Code 1596.80, are being cited on attached LIC9099D. Licensee does not ensure personnel and children's records are properly maintained.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 07-CC-20221213082756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, VANESSA
FACILITY NUMBER: 354416067
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2022
Section Cited
CCR
102416.1(a)(10)
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Personnel records shall contain a signed and dated copy of the Notice of Employee Rights (LIC 9052). This requirement was not met as evidenced by assistant Roxanna Davila did not have LIC9052 on file.
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Licensee will submit LIC9052 for assistant to CCLD by POC date.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
12/28/2022
Section Cited
CCR
102416.1(a)(11)
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Personnel records shall contain a signed statement regarding their criminal record history, and shall contain specified information. This requirement was not met as evidenced by assistant Roxanna Davila did not have LIC508 on file.
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Licensee will submit LIC508 for assistant to CCLD by POC date.
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This poses a potential risk Health, Safety Personal Rights risk to children 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.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 07-CC-20221213082756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, VANESSA
FACILITY NUMBER: 354416067
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2022
Section Cited
CCR
102416.1(a)
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102416.1(a) Personnel Records. Personnel records shall be maintained on each employee and shall contain specified information. This requirement was not met as evidenced by assistant Roxanna Davila did not have LIC9108 on file.
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Licensee will submit LIC9108 for assistant to CCLD by POC date.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
12/28/2022
Section Cited
CCR
102418(g)
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Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. This requirement was not met as evidenced by child 3 and 4 do not have immunization records on file.
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Licensee will submit immunization records for child 3 and 4 to CCLD by POC date.
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This poses a potential risk Health, Safety Personal Rights risk to children 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.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 07-CC-20221213082756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, VANESSA
FACILITY NUMBER: 354416067
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2022
Section Cited
HSC
1597.622(a)(1)
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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Licensee will submit immunizations for assistant to CCLD by POC date.
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This requirement was not met as evidenced by assistant Roxanna Davila did not have immunization record against pertussis, measles and influenza on file. This poses a potential risk Health, Safety Personal Rights risk to children 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.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 07-CC-20221213082756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, VANESSA
FACILITY NUMBER: 354416067
VISIT DATE: 12/14/2022
NARRATIVE
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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.

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: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5