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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406635
Report Date: 07/11/2023
Date Signed: 07/11/2023 04:14:23 PM

Document Has Been Signed on 07/11/2023 04:14 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:GARCIA, BLANCAFACILITY NUMBER:
434406635
ADMINISTRATOR:GARCIA, BLANCAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 347-0664
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
07/11/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Blanca GarciaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Deanna Villagrana and Licensing Program Manager (LPM) Mary Segura conducted a scheduled informal office meeting at the San Jose Regional Office with Licensee Blanca Garcia to discuss issues and citations issued on 06/29/2023. Licensee's daughter Blanca Dominguez Garcia.

On 06/29/2023, LPA conducted a Required One Year visit. LPA observed a child strapped to a stroller watching TV in the living room. LPA asked why child was strapped in. Licensee stated he bites other children but had not bitten that day. LPA observed licensee, licensee's 13 year old granddaughter, 11 month old grandson, licensee's neighbor and three day care children in the home. LPA observed licensee walk out of the home and take her 11 month old grandson to her daughter's home who lives next door at a different address. LPA explained to licensee when she returned that she could not leave children alone. LPA asked who lived in the home and licensee stated her adult daughter Blanca Dominguez Garcia and her 19 year old grandson Emiliano Dominguez. LPA observed Emiliano was not fingerprint cleared. Licensee stated he was in the home and LPA verified. Licensee left children alone without a CPR/1st Aid certified person. LPA observed a bucket of water in the dining room area accessible to children. LPA did not observe a carbon monoxide detector, a fire drill log, a current roster and a Safe Sleep log for infant in care. Children were missing immunization records, LIC995 and LIC627. Licensee submit corrections during office visit.

LPM Mary Segura, explained that if there are continued serious deficiencies cited against the facility including but not limited to citations for uncleared adults living in the home, Infant Safe Sleep regulations, Bodies of Water and Personal Rights, the license may be referred to legal for possible administrative action, which could include revocation of the facility license. The facility will be monitored more frequently to ensure that the facility is maintaining compliance with Title 22 regulations. Licensee was provided a copy of the Safe Sleep Regulations.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: GARCIA, BLANCA
FACILITY NUMBER: 434406635
VISIT DATE: 07/11/2023
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LPM Mary Segura discussed the requirements of AB 633 with Blanca Garcia and provided her with the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and she understands the requirements.
Copies of this report must be provided to parents/guardians of children currently in care at this Facility and to parents/guardians of children newly enrolled at this Facility during the next 12 months. LPM Mary Segura provided Safe Sleep regulation 102425 to licensee.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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