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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434405137
Report Date: 04/13/2023
Date Signed: 04/13/2023 12:03:47 PM

Document Has Been Signed on 04/13/2023 12:03 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: 14CENSUS: 10DATE:
04/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Elida GaetaTIME COMPLETED:
12:15 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, assistant Norma Galvan Lopez and 10 day care children including two infants.

It was observed on 04/10/2023, licensee did not maintain a sleep log for infant in care. This is a repeat violation within 12 months. A $250 civil penalty is being assessed for repeat violation.

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: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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 04/13/2023 12:03 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 04/13/2023 at 11:39 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: GAETA, ELIDA
FACILITY NUMBER: 434405137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2023
Section Cited
CCR
102425(j)(2)(D)

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Documentation shall be maintained in the infant’s file and be available to the Department for review. This requirement was not met as evidenced by It was observed on 04/10/2023, licensee did not maintain a sleep log for infant in care. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Licensee will submit a statement stating she understands she must log when infants are asleep at all times.

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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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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