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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416044
Report Date: 06/21/2024
Date Signed: 06/21/2024 12:23:13 PM

Document Has Been Signed on 06/21/2024 12:23 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:BERNAL, BRENDAFACILITY NUMBER:
434416044
ADMINISTRATOR/
DIRECTOR:		BRENDA BERNALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(646) 474-2508
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
06/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Brenda BernalTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Brenda Bernal for a case management visit. LPA explained the nature of the visit. Present were licensee, licensee's husband and adult son, 13 year old daughter, assistant and 12 day care children including four infants. Two of the children were licensee's nephew and niece who were only present for a little while their mother ran an errand.

During visit, LPA observed an infant asleep in a play yard with a blanket. Licensee's son and assistant were in same room as children watching all children. LPA explained to licensee that such items were not permitted when infants were sleeping. Licensee's son removed blanket.

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: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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 06/21/2024 12:23 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 06/21/2024 at 12:06 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: BERNAL, BRENDA
FACILITY NUMBER: 434416044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
102425(b)

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Cribs or play yards shall be free from all loose articles and objects.
This requirement was not met as evidenced by LPA observed an infant asleep in a play yard with a blanket.
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Licensee's son removed blanket during visit. Licensee stated she understand such items are not permitted. Deficiency cleared today.
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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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
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