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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416375
Report Date: 09/24/2025
Date Signed: 09/24/2025 02:57:55 PM

Document Has Been Signed on 09/24/2025 02:57 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:ROCHA, GLADYSFACILITY NUMBER:
434416375
ADMINISTRATOR/
DIRECTOR:		ROCHA, GLADYSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 466-1261
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
09/24/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:27 AM
MET WITH:Karina Xavier Dos Santos, Maira Gomez Caicedo and Gladys RochaTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Mandeep Kaur conducted an unannounced Plan of Correction inspection to the facility. At 09:30AM, LPA was allowed the entry to the facility by Assistant, Karina Xavier Silva Dos Santos. LPA met with Assistant, Karina Xsvier Dos Santos and explained the nature of this inspection. LPA toured indoor and outdoor areas of the facility with Assistant, Karina Xavier Dos Santos. Present were total of 12 children (8 preschoolers and 4 infants) with one assistant, Karina Xavier Dos Santos and an Adult/chef, Victor Lazaro Cruz. LPA observed an adult/Chef, Victor Lazaro Cruz in the kitchen, offlimit area.

LPA observed an Assistant, Karina Xavier Dos Santos with 12 children (8 preschool age and 4 infants). Assistant stated that there is no other staff is present to supervise the 12 children. Assistant stated that Licensee, Gladys Rocha will be at the facility in about five minutes. LPA observed facility is out of ratio during today's inspection that is the second violation within a month period. On 09/15/2025, facility was cited under Title 22 regulations section code: 102416.5(d)(2) Staffing ratio and capacity.

At 09:35AM, LPA observed second assistant, Maira Gomez Caicedo who does not have criminal background clearance arrived at the facility. Ms. Maira Gomez Caicedo was observed to be supervising the children present at day care home during today's inspection. On 09/15/2025, The facility was cited under criminal record clearance section code: 102370(d)(1) for not having criminal background clearance for the staff present on 09/15/2025 including Ms. Maira Gomez Caicedo.

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NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Mandeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/24/2025 02:57 PM - It Cannot Be Edited


Created By: Mandeep Kaur On 09/24/2025 at 11:08 AM
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: ROCHA, GLADYS
FACILITY NUMBER: 434416375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2025
Section Cited
CCR
102416.5(d)(2)

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Staffing Ratio and Capacity: (d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.

This requirement was not met as evidenced by:
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By plan of correction due date, 09/26/2025, Licensee shall submitt the written statement of understaing of Title 22 section code: 102416.5(d)(2) that they are not going to operate out of ratio again including the future plan of having additional personell with Criminal Background clearance.
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Based on observation, upon arrival at 09:30AM, LPA observed 12 children (8 preschool and 4 infants) present with one assistant, Karina Xavier Dos Santos during today's inspection, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Immediate civil penalty of $250 assessed during today's inspection.

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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.
Susy Cervantes
NAME OF LICENSING PROGRAM MANAGER:
Mandeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: ROCHA, GLADYS
FACILITY NUMBER: 434416375
VISIT DATE: 09/24/2025
NARRATIVE
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At 09:45AM, Licensee, Gladys Rocha arrived at the facility. Licensee stated that Ms. Maira Gomez Caicedo is here to help the facility to take care of the children present. Licensee stated that she asked Ms. Maira Gomez Caicedo to come for help for 15 minutes. At 09:51AM, Licensee asked Maira Gomez Caicedo to leave the facility.

During today's inspection, Licensee was advised of Title 22 required regulations section code: 102423: personal rights.

During today's inspection, Type B citation issued on attached form:809 D. Civil penalty of $800 is assessed- Failure to correct for the the violation of California Code of Regulations section code 102416(d)(2) and immediate civil penalty of $250 is assessed for the repeat violation of California Code of Regulations section code 102416.5(d)(2). During today's inspection, Total civil penalty of $1050 assessed.

Exit interview conducted and report was reviewed with the Licensee, Gladys Rocha. Appeal rights provided.

A notice of site visit was given and must remain posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Mandeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC809 (FAS) - (06/04)
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