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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416004
Report Date: 04/08/2024
Date Signed: 04/08/2024 04:25:25 PM

Document Has Been Signed on 04/08/2024 04:25 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:CASILLAS, MARIAN & SANDOVAL, JUANFACILITY NUMBER:
434416004
ADMINISTRATOR/
DIRECTOR:		MARIAN CASILLAS & JUAN SANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 771-1463
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 14TOTAL ENROLLED CHILDREN: 19CENSUS: 9DATE:
04/08/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Marian CasillasTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Deanna Villagrana and Martha Villanueva-Jimenez met with licensee Marian Casillas for a case management visit. Licensee is requesting to add two additional rooms. Present were licensee Marian Casillas, assistant Helen Vargas and nine day care children including four infants.

The Department received a fire clearance on 04/04/2024 from San Jose Fire Department. An inspection was approved on 03/27/2024 to use the two additional rooms. LPAs observed the Notice of Site was posted for report dated on 03/14/2024 and review two children's files and one staff file. All children's files are complete and children have LIC9224 on file. Assistant Helen Vargas does not have pertussis immunization on file.

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: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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 04/08/2024 04:25 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 04/08/2024 at 04:13 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: CASILLAS, MARIAN & SANDOVAL, JUAN
FACILITY NUMBER: 434416004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2024
Section Cited
HSC
1597.622(a)(1)

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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Licensee will submit pertussis immunization for assistant Helen Vargas to CCLD by POC date.
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This requirement was not met as evidenced by Assistant Helen Vargas does not have pertussis immunization on file. 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: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024


LIC809 (FAS) - (06/04)
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