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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416762
Report Date: 08/04/2023
Date Signed: 08/17/2023 10:16:55 AM

Document Has Been Signed on 08/17/2023 10:16 AM - 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:ORTEGA, ANA KARINAFACILITY NUMBER:
434416762
ADMINISTRATOR:ORTEGA, ANA KARINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 843-8923
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 21DATE:
08/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ana Karina OrtegaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee, Ana Karina Ortega for a case management inspection. LPA observed 21 children in care during today's inspection.
The Licensee will be subject to additional visits to ensure that she is within capacity requirements for a large family child care home.
LPA notes that a follow up inspection will be made to discuss today's inspection. Licensee was not truthful with LPA and did not provide LPA with correct names of children.


NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS ALONG SIDE TYPE A DEFICIENCY.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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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Document Has Been Signed on 08/17/2023 10:16 AM - It Cannot Be Edited


Created By: Elizabeth Berumen On 08/04/2023 at 01:16 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: ORTEGA, ANA KARINA
FACILITY NUMBER: 434416762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
Section Cited
CCR
102416.5

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(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement was not met as evidenced by:
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Licensee states she is going comply with the Staffing Ratio and Capacity regulation. She agreed to speak to parents and withdraw 7 children. License agrees to submit an updated roster by plan of correction date of August 4, 2023.
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The Licensee was caring for 21 children (5 children present were infants) more than her licensed capacity, which poses an immediate risk to the health, safety, and personal rights of children in care.
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LIC9224 must be signed by all parents currently enrolled and submitted to Licensing by end of day 08/07/23. LIC9224 and LIC809 and 809D must be provided to all future enrollments for the next 12 months and maintained in file.

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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:Mary Segura
LICENSING EVALUATOR NAME:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


LIC809 (FAS) - (06/04)
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