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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434405137
Report Date: 09/07/2022
Date Signed: 09/07/2022 03:31:09 PM

Document Has Been Signed on 09/07/2022 03:31 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:GAETA, ELIDAFACILITY NUMBER:
434405137
ADMINISTRATOR:GAETA, ELIDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 842-6174
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
09/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Elida GaetaTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Elida Gaeta for a Case Management visit. Present were licensee, licensee's husband, adult son, granddaughter (3 years old), assistant Norma Galvan Lopez and seven day care children including three infants.

LPA observed Lissette De La Torre who licensee was cited for not having clearance on 08/19/2022 during visit is no longer living in the home. LPA observed all required posting for Type A deficiencies cited on 08/19/2019. Child 1 is missing LIC9224. LPA observed immunization against measles, pertussis and influenza for assistant Norma Galvan Lopez. Licensee submitted a letter to LPA stating she understands day care children may not utilize living rooms or bedrooms. LPA did not observed a Mandated Reporter Certificate for Norma Galvan Lopez which was due on 09/02/2022. A $500 civil penalty is being assessed for failure to correct deficiency.

The following type B deficiency was cited on the attached page (809-D). Licensee was informed that failure to correct the deficiency 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: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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 09/07/2022 03:31 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 09/07/2022 at 03:14 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: GAETA, ELIDA
FACILITY NUMBER: 434405137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2022
Section Cited
HSC
1596.8595(c)

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A licensed child care facility or home shall provide to the parents 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 as specified in paragraph (1) of subdivision (a) of Section 1596.893b.
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Licensee will submit LIC9224 for child 1 to CCLD by POC date.
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This requirement was not met as evidenced by Child 1 is missing LIC9224. 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.
SUPERVISOR'S NAME:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022


LIC809 (FAS) - (06/04)
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