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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434416762
Report Date: 02/20/2025
Date Signed: 02/20/2025 11:10:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2024 and conducted by Evaluator Liridon Fici
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20241227125919
FACILITY NAME:ORTEGA, ANA KARINAFACILITY NUMBER:
434416762
ADMINISTRATOR:ORTEGA, ANA KARINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 843-8923
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 21DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:ORTEGA, ANA KARINATIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Licensee did not report injury to child's parent.
Licensee did not maintain complete records for child in care.
INVESTIGATION FINDINGS:
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On 2/20/2025, at 9:15AM, Licensing program analyst (LPA), Liridon Fici- Doni arrived unannounced to conduct a complaint investigation, and was greeted by licensee, ORTEGA, ANA KARINA, and explained the purpose of today’s visit. LPA observed 21 children, and two (2) staff members during visit.

During the course of the investigation, LPA interviewed two (2) staff, conducted children’s file review, and collected the following document: Children’s roster, children’s emergency information contact form, ring video recording, and incident report.

It was alleged that, Licensee did not report injury to child's parent and Licensee did not maintain complete records for child in care.

Page 1 of 2...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 07-CC-20241227125919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ORTEGA, ANA KARINA
FACILITY NUMBER: 434416762
VISIT DATE: 02/20/2025
NARRATIVE
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Based on interview conducted with Licensee, Licensee confirmed with LPA that she did not inform child 1 (C1’s) parent of the incident that occurred on 12/26/2024 and that Licensee also admitted a child into care without maintaining completed records for C1. LPA reviewed video recording of the incident that occurred on 12/26/2024 which corroborates with the interview conducted with Licensee.

Based on interviews, record review, and evidence gathered during the investigation process, the Department concludes that Licensee did not report injury to child's parent and Licensee did not maintain complete records for child in care. The above allegation is thus found to be SUBSTANTIATED, meaning the allegations are valid because the preponderance of the evidence standard has been met.

The following type B deficiency was cited on the attached page (9099-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.

Exit interview conducted with Licensee, and this report reviewed and provided along with appeal rights.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 07-CC-20241227125919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ORTEGA, ANA KARINA
FACILITY NUMBER: 434416762
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2025
Section Cited
CCR
102416.2(f)
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102416.2(f)-Reporting Requirements: (f) As soon as possible but no later than the same business day, the licensee shall notify a child's parent or authorized representative regardless of the injuries or acts that affect that child...
This requirement is not met as evidenced by:
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Licensee agreed to reviewed section 102416.2-Reporting Requirements and to compose a letter adhearing to the regulation and to sign, dated, and submit a copy to CCL by the POC due date.
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Based on interviews, the licensee did not comply with the section cited above by not informing Child 1 (C1's) parent of the incident that occured on 12/26/2024, which poses a potential health, safety, or personal rights risk to persons in care.
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Type B
02/27/2025
Section Cited
CCR
102419(d)(1)
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102419(d)(1)- Admission Procedures and Parental and Authorized Representative's Rights- (d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parents’ Rights, LIC 995A... (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995
This requirement is not met as evidenced by:
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Licensee agreed to reviewed section 102419- Admission Procedures and Parental and Authorized Representative's Rights and to compose a letter adhearing to the regulation and to sign, dated, and submit a copy to CCL by the POC due date.
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Based on interviews, the licensee did not comply with the section cited above by not having Child 1 (C1's) parent sign and date C1's child records, which poses a potential health, safety, or personal rights risk to persons 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.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 07-CC-20241227125919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ORTEGA, ANA KARINA
FACILITY NUMBER: 434416762
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2025
Section Cited
CCR
102418(g)
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102418(g): Immunizations- (g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
This requirement is not met as evidenced by:
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Licensee agreed to reviewed section 102418: Immunizationss and to compose a letter adhearing to the regulation and to sign, dated, and submit a copy to CCL by the POC due date.
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Based on interview, the licensee did not comply with the section cited above by not having a complete child's record for C1 in care prior to admission, which poses a potential health, safety, or personal rights risk to persons in care.
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Type B
02/27/2025
Section Cited
CCR
102421(b)
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102421(b)-Child's Records: (b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7).


This requirement is not met as evidenced by:
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Licensee agreed to reviewed section 102421: Child's Records and to compose a letter adhearing to the regulation and to sign, dated, and submit a copy to CCL by the POC due date.
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Based on interview conducted, the licensee did not comply with the section cited above in not maintaining C1's records prior to being admitted into care, which poses a potential health, safety, or personal rights risk to persons 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.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4