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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416493
Report Date: 08/01/2023
Date Signed: 08/01/2023 03:07:49 PM

Document Has Been Signed on 08/01/2023 03:07 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CACERES AGELVIZ, RAMON & RODRIGUEZ AGELVIS, MILLYFACILITY NUMBER:
434416493
ADMINISTRATOR:RAMON & MILLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 233-1595
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 14TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
08/01/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Milly Rodriguez AgelvisTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Mel Matos met with Milly Rodriguez Agelvis, co-Licensee, for an unannounced case management inspection. Purpose of today's inspection: Licensees submitted an updated Facility sketch advising that all three bedrooms (including master bedroom) in the home are "off limits" as of July 21, 2023. One of the three bedrooms was previously used for the day care prior to July 21, 2023.

LPA toured the indoor and outdoor areas of the home with Milly during today's inspection. LPA also observed five napping day care children (4 infants & 1 preschool) and one of Licensees adult daughters (Patricia Caceres Rodriguez) in the home during today's inspection.

There are no stairs or wall heater units inside the home. Current off limit areas in the home: master bedroom, master bathroom, two bedrooms, furnace closet, locked bathroom vanity cabinet door, barricaded fireplace (located in the living room), and attached garage. Current off limit areas outside the home: front yard and right side area of the backyard.

No updated fire clearance is required since the fire marshal did not list which areas of the home were off limits during the previous inspection on August 30, 2021.

Milly also provided LPA with updated CPR/First Aid certifications for both Licensees (exp: 06/10/2025) during today's inspection.

Exit interview conducted and report was reviewed with the Licensee, Milly Rodriguez Agelvis. No deficiencies issued during today's inspection. Notice of site visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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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