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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416762
Report Date: 12/05/2023
Date Signed: 12/05/2023 03:22:03 PM

Document Has Been Signed on 12/05/2023 03:22 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: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: 9DATE:
12/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Ana Karina OrtegaTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management-Other inspection. LPA met with Licensee Ana Karina Ortega and explained the reason for the inspection. The purpose of this inspection is to discuss an incident that occurred on 08/14/2023 and violation of personal rights. Present during today's inspection were Licensee, her assistant, and nine children, whom three were infant age.

Based on the incident that occurred on 08/14/2023, Licensee's son had told LPA Berumen that he was a parent. He attempted to picked up an infant in care. Licensee's son later stated he was not the parent of the infant.

As a result of this inspection, a Type B citation was issued. Exit interview conducted and report was reviewed with Licensee Ana Karina Ortega. A notice of site visit has been issued and must remain posted 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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 12/05/2023 03:22 PM - It Cannot Be Edited


Created By: Samantha Yip On 12/05/2023 at 12:26 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: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2023
Section Cited
CCR
102423(a)(2)

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Personal Rights. Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
This requirement is not met as evidenced by:
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By 12/12/2023, Licensee will submit written statement outlining that she understands that she cannot have anymore attempt to pick up a child
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Based on observation and interview, on 08/04/2023, Licensee's son lied that he was a parent of an infant and attempted to pick up the infant. This poses a potential health and safety risk to children in care.
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who they are not authorized.

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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


LIC809 (FAS) - (06/04)
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