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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412779
Report Date: 06/03/2024
Date Signed: 06/03/2024 04:07:10 PM

Document Has Been Signed on 06/03/2024 04:07 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GONZALEZ, ARCELIAFACILITY NUMBER:
434412779
ADMINISTRATOR/
DIRECTOR:		GONZALEZ, ARCELIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 310-0239
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 6DATE:
06/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:40 PM
MET WITH:Arcelia GonzalezTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Arcelia Gonzalez for a case management visit. LPA explained the nature of the visit. Present were licensee, licensee's assistant Elena Barba, her two 16 year old son and six day care children including two infants.

During visit, LPA observed live cockroaches in the facility. LPA informed licensee and licensee killed two of them.

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: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/03/2024 04:07 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 06/03/2024 at 03:47 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: GONZALEZ, ARCELIA
FACILITY NUMBER: 434412779

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2024
Section Cited
CCR
102417(g)

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The home shall be free from defects or conditions which might endanger a child. This requirement was not met as evidenced by LPA observed live cockroaches in the facility.
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Licensee stated she will disinfect and spray her home to get rid of cockroaches.
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This poses a potential risk Health, Safety Personal Rights risk to children 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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024


LIC809 (FAS) - (06/04)
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