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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416762
Report Date: 08/17/2023
Date Signed: 08/22/2023 10:06:35 AM

Document Has Been Signed on 08/22/2023 10:06 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: 12DATE:
08/17/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ana Karina OrtegaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst's (LPAs) Elizabeth Berumen and Deanna Villagrana met with Licensee, Ana Karina Ortega and explained the purpose of today's inspection with her. The purpose of today's inspection was to Upon arrival LPA's observed 11 day care children including three infants, Licensee's assistants; Margaret Salas and Jessica Gutierrez.

On August 4, 2023 Licensee, Ana Karina was cited a Type A deficiency for being over capacity. Licensee, Ana Karina failed to comply with the plan of correction.


Licensee did not post report dated August 4, 2023 along with type A deficiency. LPA Berumen observed only nine out of 21 children's files had LIC9224 signed by parents. LPAs observed another child (infant) crawling on the floor with dirt on his knees. LPAs observed the floors and carpet are not clean including a large orchid leaf in the entryway were children crawl and walk. LPAs observed one child (age 4) strapped to a booster seat on a kitchen counter stool.
LPA Deanna Villagrana observed toothpaste in a bathroom drawer and Pepto Bismol in a kitchen drawer accessible to children. This is a repeat violation with 12 months. A $250 civil penalty is being assessed. LPAs did not observe a current roster of children. Three additional school age children arrived in the afternoon. All three children are in Kindergarten. Licensee was operating out of ratio, three infants, eight preschool children and three kindergarten children none who were age six.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies 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.

LPAs Elizabeth Berumen and Deanna Villagrana informed licensee Ana Karina Ortega that this report dated 08/17/2023 document(s) 5 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 08/22/2023 10:06 AM - It Cannot Be Edited


Created By: Elizabeth Berumen On 08/17/2023 at 02:19 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: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2023
Section Cited
CCR
102423(a)(2)

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To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement was not met as evidenced by: LPAs observed one child (age 4) strapped to a booster seat on a kitchen counter
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Licensee removed child during visit. Licensee will submit a statement stating she understands children must not be restrained.
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stool which poses an immediate risk to the health, safety, and personal rights of children in care.
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Type A
08/17/2023
Section Cited
HSC1596.8595(a)(1)

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Each licensed child day care facility shall post a copy of any licensing report pertaining to the facility that documents either a facility visit or a complaint investigation that results in a citation for a violation that, if not corrected, will create a direct and immediate risk to the health, safety, or personal rights of children in care. The licensing report provided by the department shall be posted immediately upon receipt, adjacent to the postings required pursuant to Section 1596.817 and on, or immediately adjacent to, the interior side of the main door to the facility and shall remain posted for 30 consecutive days.
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Licensee posted August 4, 2023 report along with type A violation so parents can review. Deficiency cleared today.
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This requirement was not met as evidenced by: Licensee did not post report dated August 4, 2023 along with type A deficiency for parents to review which poses an immediate risk to the health, safety, and personal rights of 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:Mary Segura
LICENSING EVALUATOR NAME:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


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Document Has Been Signed on 08/22/2023 10:06 AM - It Cannot Be Edited


Created By: Elizabeth Berumen On 08/17/2023 at 02:31 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: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited
HSC
1596.8595(c)

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A licensed child care facility or home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as specified in paragraph (1) of subdivision (a) of Section 1596.893b.
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Licensee will have all parents complete LIC9224 and submit proof to CCLD by POC date.
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This requirement was not met as evidenced by: LPA Berumen observed only nine out of 21 children's files had LIC9224 signed by parents which poses an immediate risk to the health, safety, and personal rights of children in care.
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Type A
08/18/2023
Section Cited
CCR102417(g)(4)

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Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
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Licensee removed items during visit. Deficiency cleared today.
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This requirement was not met as evidenced by: LPA Deanna Villagrana observed toothpaste in a bathroom drawer and Pepto Bismol in a kitchen drawer accessible to children which poses an immediate risk to the health, safety, and personal rights of 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:Mary Segura
LICENSING EVALUATOR NAME:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


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Document Has Been Signed on 08/22/2023 10:06 AM - It Cannot Be Edited


Created By: Elizabeth Berumen On 08/17/2023 at 02:43 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: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2023
Section Cited
CCR
102417(b)

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The home shall be kept clean and orderly, with heating and ventilation for safety and comfort. This requirement was not met as evidenced by: LPAs observed the floors and carpet are not clean including and large orchid leaf in the entryway were children crawl
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Licensee will submit photos of a cleaned carpet and floor to CCLD by POC date.
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and walk which poses a potential risk to the health, safety, and personal rights of children in care.
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Type B
08/24/2023
Section Cited
CCR102417(g)(8)

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met as evidenced by: LPAs did not observe a current roster of children
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Licensee will submit a current roster to CCLD by POC date.
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which poses a potential risk to the health, safety, and personal rights of 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:Mary Segura
LICENSING EVALUATOR NAME:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


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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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ORTEGA, ANA KARINA
FACILITY NUMBER: 434416762
VISIT DATE: 08/17/2023
NARRATIVE
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Also, LPAs Elizabeth Berumen and Deanna Villagrana informed the licensee Ana Karina Ortega to provide a copy of this licensing report dated 08/17/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Licensee will also be required to attend a meeting in the San Jose Regional office to address citations issued. A letter will be mailed to Licensee informing her of date and time.

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: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2023 10:06 AM - It Cannot Be Edited


Created By: Elizabeth Berumen On 08/17/2023 at 03:42 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: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited
HSC
1597.465

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Health and Safety Code section 1597.465 states:
A large family day care home may provide care for more than 12 children and up to and including 14 children, if all of the following conditions are met: (a) At least one child is enrolled in and attending kindergarten or elementary school and a second child is at least six years of age.
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Licensee to submit a written plan of correction including the names of children who she will terminate at end of business day today to ensure she is in complaince.
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This requirement was not met as evidenced by: LPA Berumen and Villagrana observed 14 children in care; 3 infants, 8 preschoolers and 3 school age children under the age of 6.
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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: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


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