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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409640
Report Date: 05/31/2023
Date Signed: 05/31/2023 11:06:07 AM

Document Has Been Signed on 05/31/2023 11:06 AM - 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:HERNANDEZ, LORENAFACILITY NUMBER:
434409640
ADMINISTRATOR:LORENA HERNANDEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 334-9528
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
05/31/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Lorena HernandezTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Janette Cruz, met with Lorena Hernandez, to conduct an unannounced Plan of Correction (POC) inspection. Purpose of today’s inspection: verify completion of the Plans of Correction resulting from the previous case management inspection completed on 05/17/2023. LPA toured indoor and outdoor areas of the facility. LPA observed Licensee's spouse, Gustavo Hernandez and four children with (one infant, three preschool) present during today's inspection.

The facility was issued the following Type B deficiencies on 05/17/23:
1.CCR 102425(b) - Infant Safe Sleep - LPA Cruz and LPM Stephenson observed an infant in care, child (C1) was swaddled, had blanket on also had other pillows and toys during naptime inside the infant play yard
2. CCR 102425(j)(2)(D) Infant Safe Sleep - Licensee did not maintain documentation of sleep check for child (C1)
3. CCR 102425(c)(1)(2) Infant Safe Sleep - Licensee did not maintain LIC9227 Infant Sleeping Plan for child (C1)
4. CCR 102417(8)(a) Operation of a Family Child Care Home - Licensee did not maintain a current child care roster with complete information of children in care

LPA reviewed plans of correction for Type B deficiencies cited on 5/17/23 during today's visit. POC clearance issued.

No deficiencies cited during today's inspection. An exit interview was conducted with Lorena Hernandez, Licensee.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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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