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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413945
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:46:08 PM

Document Has Been Signed on 10/29/2024 12:46 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:VENZON, NATALYAFACILITY NUMBER:
434413945
ADMINISTRATOR/
DIRECTOR:		VENZON, NATALYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 603-5656
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
10/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Daria MoiseevaTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an Case Management-Other inspection. LPA met with Assistant Daria Moiseeva and explained the reason for the inspection. LPA was allowed into the home at 12PM. Assistant stated that Licensee is currently out of town and will be returning 10/30/2024. The purpose of this inspection is Licensee was cited for children's paperwork. Licensee was also asked to submit documents, such as facility roster, parent consent and physician's order for medication, and an updated medication box to match the medication in the home.

During today's inspection, LPA observed that an updated medication box was obtained that matches the medication in the home for C-1. Assistant stated that C-1 is currently out of town and will be returning next week. C-1 does not have written permission from parent for the family child care home to administer medication, nor the physician's order.

LPA reviewed C-2's file and observed that child is missing LIC 995A. LPA observed updated facility roster. Assistant stated that Licensee will send facility roster a copy to Licensing.

Licensee will submit by 10/30/2024:
- facility roster
- communication to C-1 to obtain written permission and physician's order
- proof of daycare insurance
- LIC 995A for C-2

As a result of this inspection, a Type B citation was issued. Exit interview conducted and report was reviewed with Assistant Daria Moiseeva. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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 10/29/2024 12:46 PM - It Cannot Be Edited


Created By: Samantha Yip On 10/29/2024 at 12:27 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: VENZON, NATALYA
FACILITY NUMBER: 434413945

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2024
Section Cited
CCR
102419(d)(1)

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Admission Procedures and Parental and Authorized Representative's Rights. The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver Background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).
This requirement is not met as evidenced by:
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By 11/05/2024, Licensee will have C-2's parent fill out and sign LIC 995A and submit proof to Licensing.
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Based on record reviews, C-2 does not have signed LIC 995A on file, which poses a potential health and safety 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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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