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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410917
Report Date: 10/27/2023
Date Signed: 10/27/2023 04:27:43 PM

Document Has Been Signed on 10/27/2023 04:27 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:AGUSTIN, DEOTINAFACILITY NUMBER:
434410917
ADMINISTRATOR:DEOTINA AGUSTINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 258-1944
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 14TOTAL ENROLLED CHILDREN: 15CENSUS: 12DATE:
10/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Deotina AgustinTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janette Cruz conducted an unannounced case management during another visit and met with Deotina Agustin, Licensee. LPA observed 12 day care children (3 infants, 9 preschool) and Licensee's adult assistants (Tham Nguyen, Gloria Mora & Ximena Capetillo Buenro) present during today's inspection. LPA reviewed staff and children's files.

A deficiency was cited, appeal rights were given to Licensee, See (809-D). Exit interview was conducted with Deotina Agustin, Licensee.

A Notice of Site Visit was issued and must be posted for 30 days.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2023 04:27 PM - It Cannot Be Edited


Created By: Janette Cruz On 10/27/2023 at 03:19 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: 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 B
11/10/2023
Section Cited
HSC
1596.8662(b)(1)

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1596.8662(b) (1)   On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement was not met as evidenced by:
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Licensee will submit Mandated Reporter training for staff S4 by POC due date.
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Based on record review, Licensee did not comply with the section cited above. Licensee did not obtain Mandated Reporter Training certification for staff S4 which posed a potential 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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