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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417603
Report Date: 04/21/2023
Date Signed: 04/21/2023 03:18:14 PM

Document Has Been Signed on 04/21/2023 03:18 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:ROCHA ORTEGA, ANAFACILITY NUMBER:
434417603
ADMINISTRATOR:ANA ROCHA ORTEGAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 310-6788
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 5DATE:
04/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Ana Rocha OrtegaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensee Program Analyst (LPA) Deanna Villagrana met with licensee Ana Rocha Ortega to for a case management visit. LPA explained the nature of the visit. Present were licensee, licensee's adult daughter Laura Rocha Ramos and five day care children including two infants.

LPA observed to children ages four in a play yard, one was sleeping and the other awake. Children were long and did not fit comfortably in the play yard. LPA observed an infant in a play yard with a blanket.

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.

LPA Deanna Villagrana informed licensee Ana Rocha Ortega that this report dated 04/21/2023 document(s) 1 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.

Also, LPA Deanna Villagrana informed the licensee Ana Rocha Ortega to provide a copy of this licensing report dated 04/21/2023 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.

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: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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 04/21/2023 03:18 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 04/21/2023 at 02:51 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: ROCHA ORTEGA, ANA
FACILITY NUMBER: 434417603

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
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 LPA observed to children ages four in a play yard, one was sleeping and the other awake. Children were long and did not fit comfortably in the play yard.
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Licensee removed child who was awake and placed on a cot. Licensee stated she will no longer use play yard for older children and will use a cot.
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This poses a potential risk Health, Safety Personal Rights risk to 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:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2023 03:18 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 04/21/2023 at 03:14 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: ROCHA ORTEGA, ANA
FACILITY NUMBER: 434417603

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2023
Section Cited
CCR
102425(b)

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Cribs or play yards shall be free from all loose articles and objects. This requirement was not met as evidenced by LPA observed an infant in a play yard with a blanket.
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Licensee removed blanket during visit. Licensee will submit a statement stating she understands regulation.
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This poses an immediate risk to the Health, Safety or Personal Rights to 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:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
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