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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434410917
Report Date: 10/27/2023
Date Signed: 10/27/2023 04:26:15 PM

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
10/25/2023 and conducted by Evaluator Janette Cruz
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20231025161136
FACILITY NAME:AGUSTIN, DEOTINAFACILITY NUMBER:
434410917
ADMINISTRATOR:DEOTINA AGUSTINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 258-1944
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:14CENSUS: 12DATE:
10/27/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Deotina AgustinTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility was operating over licensed capacity.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janette Cruz conducted an unannounced complaint investigation and met with Deotina Agustin, Licensee. LPA also observed 12 children
(3 infants, 9 preschool) and three adult assistants (Tham Nguyen, Gloria Mora & Ximena Capetillo Buenro) present in the home during today's complaint investigation.
Based on the available evidence, record reviews and interviews conducted, it is concluded and Licensee admitted to having at least 14 children (4 infants, 10 preschool) present in her daycare on 10/24/2023. The preponderance of evidence standard has thus been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 12 & Chapter 1), is being cited on the attached LIC 9099-D. Copy of appeal rights provided to Licensee, prior to conclusion of today’s inspection.

LPA discussed the requirements of AB633 to Licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Licensee understands the requirements. Upon receipt, Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Exit interview conducted and report was reviewed with Deotina Agustin, Licensee.
A notice of site visit was given and must remain posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
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 2
Control Number 07-CC-20231025161136
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: AGUSTIN, DEOTINA
FACILITY NUMBER: 434410917
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2023
Section Cited
HSC
1597.465(a)(b)
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1597.465 Large family day care homes; number of children

A large family day care home may provide care for more than 12 children and up to and including 14 children, if all of the following conditions are met:
(a) At least one child is enrolled in and attending kindergarten or elementary school and a second child is at least six years of age.
(b) No more than three infants are cared for during any time when more than 12 children are being cared for. This requirement is not met as evidenced by:
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Licensee agreed to submit a written plan of correction that states her understanding that she cannot exceed her licensed capacity and ratio by POC due date 10/30/23.
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Based on the observation, interview and record reviews and interviews conducted, Licensee did not comply with section cited above. Licensee admitted to having at least 14 children (4 infants, 10 preschool) present in her daycare on 10/24/2023 which posed immediate health, safety or personal rights risk to persons 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: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2