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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417657
Report Date: 02/11/2025
Date Signed: 02/11/2025 02:08:28 PM

Document Has Been Signed on 02/11/2025 02:08 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CARRILLO HERNANDEZ, TANYAFACILITY NUMBER:
434417657
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 3CENSUS: 3DATE:
02/11/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Tanya Carrillo HernandezTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee's assistant Marcela Carballo for an annual/random visit. LPA explained the nature of today’s inspection to her. Present were assistant and three day care children including one infant. Licensee and licensee's husband arrived during visit with lunch for the children. Days and hours of operation are Monday to Friday, 7:00am to 5:00pm. The adults that reside in the home are licensee, her husband, and her adult sister Abigail Carrillo Hernandez.

A review of staff records on 01/28/2025 indicates that not all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Abigail Carrillo Hernandez does not have fingerprint clearance. Licensee Tanya Carrillo Hernandez was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.


LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed a barricaded fireplace in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged 3A40BC fire extinguisher and a working combo smoke and carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: master bedroom/bath, three bedrooms, kitchen and attached garage. LPA observed an in grown pool with the proper fencing including a mesh fence that meets ASTM-F2286 approval. LPA did not observe a require pool cover or a pool alarm in addition to a life ring and a rescue pole. Licensee stated she did not have a daily inspection log. Backyard is fenced. Off limits outdoor: left side of home that is fenced off to children were the pool is located
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CARRILLO HERNANDEZ, TANYA
FACILITY NUMBER: 434417657
VISIT DATE: 02/11/2025
NARRATIVE
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including the patio near the kitchen. Licensee uses right side back of the home and access the area through the front right gate. LPA observed two dogs and one cat in the home and licensee states they are vaccinated. LPA observed licensee has a current CPR and First Aid certification expiring 05/2026 and completed Mandated Reporter training on 08/16/2022. Licensee's assistant had a CPR and First Aid certification that was not EMSA approved. Assistant completed Mandated Reporter training on 01/25/2025.

LPA observed a current roster of the children. Licensee stated she does not have a fire and disaster drill log. LPA reviewed three children's files. Child 2 did not have immunization records on file. Child 1 and 2 are missing LIC995. Licensee stated she did not have a Safe Sleep log for infant in care. LPA observed day care is insured with Acord and expires 01/31/2026. LPA discussed SB792 Immunization Requirements and observed licensee and her assistant have immunization records on file.



Supervision of children was discussed with licensee, and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than eight children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed the safe sleep regulations with licensee Tanya Carrillo Hernandez and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee Tanya Carrillo Hernandez of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
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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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CARRILLO HERNANDEZ, TANYA
FACILITY NUMBER: 434417657
VISIT DATE: 02/11/2025
NARRATIVE
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensee Tanya Carrillo Hernandez was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California .

Exit interview conducted and report was reviewed with the licensee Tanya Carrillo Hernandez.

During the exit interview, the LICENSEE Tanya Carrillo Hernandez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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 Tanya Carrillo Hernandez that this report dated 02/11/2025 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 Tanya Carrillo Hernandez to provide a copy of this licensing report dated 02/11/2025 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 to Tanya Carrillo Hernandez and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 02/11/2025 02:08 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 02/11/2025 at 01:17 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: CARRILLO HERNANDEZ, TANYA
FACILITY NUMBER: 434417657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Abigail Carrillo Hernandez does not have fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
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Licensee understands Abigail Carrillo Hernandez may not return to the home until clearance is obtained.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 02/11/2025 02:08 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 02/11/2025 at 01:17 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: CARRILLO HERNANDEZ, TANYA
FACILITY NUMBER: 434417657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Licensee stated she does not have a fire and disaster drill log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Licensee will conduct a fire and disaster drill and submit log to CCLD by POC date.
Type B
Section Cited
HSC
1596.814(a)(1)(B)(i)(I)
Pool Safety
(i) (I) An approved safety pool cover that is manually or power operated and meets the performance standards of ASTM International Standard F1346-23.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA did not observe an approved safety pool cover or pool alarm which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Licensee will purchase a pool cover that meets ASTM International Standard F1346-23 standards and or pool alarm and provide proof to CCLD by POC date.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2025 02:08 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 02/11/2025 at 01:17 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: CARRILLO HERNANDEZ, TANYA
FACILITY NUMBER: 434417657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(1)(B)(ii)(I)
Pool Safety
(ii) (I) An alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water. The alarm shall be turned on and be in working condition during a facility’s operating hours while the swimming pool is not in use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA did not observe an approved safety pool cover or pool alarm which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Licensee will purchase a pool cover that meets ASTM International Standard F1346-23 standards and or pool alarm and provide proof to CCLD by POC date.
Type B
Section Cited
HSC
1596.814(a)(2)(A)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (A) A life ring with a minimum exterior diameter of 17 inches and labeled as approved by the United States Coast Guard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA did not observe a life ring which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Licensee will purchase required life ring and submit proof to CCLD by POC date.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 02/11/2025 02:08 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 02/11/2025 at 01:17 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: CARRILLO HERNANDEZ, TANYA
FACILITY NUMBER: 434417657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(2)(B)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (B) A rescue pole with a body hook and a minimum fixed length of 12 feet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA did not observe a required rescue pole meeting standards which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Licensee will purchase the required rescue pole and submit proof to CCLD by POC date.
Type B
Section Cited
HSC
1596.814(a)(3)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (3) A licensee shall perform a daily inspection of the drowning prevention safety features and safety equipment before opening the facility and maintain a log of the inspections to be provided to the department upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview, the licensee did not comply with the section cited above. Licensee stated she did not have a daily inspection log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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2
3
4
Licensee will submit a statement stating she has read Pool Safety Regulations and submit log beginning today to CCLD by POC date. A copy of regulations were provided to licensee.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 02/11/2025 02:08 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 02/11/2025 at 01:17 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: CARRILLO HERNANDEZ, TANYA
FACILITY NUMBER: 434417657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Licensee completed Mandated Reporter training on 08/16/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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2
3
4
Licensee will submit an updated Mandated Reporter certificate for herself to CCLD by POC date. Training can be found at www.mandatedreporterca.com
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Licensee's assistant had a CPR and First Aid certification that was not EMSA approved which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
1
2
3
4
Licensee will submit an EMSA approved CPR and First Aid certification or a letter stating she understands she may not leave assistant alone without required certificate to CCLD by POC date.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 02/11/2025 02:08 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 02/11/2025 at 01:17 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: CARRILLO HERNANDEZ, TANYA
FACILITY NUMBER: 434417657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Child 2 did not have immunization records on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2025
Plan of Correction
1
2
3
4
Licensee printed out immunization records for child 2. Deficiency cleared today.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 02/11/2025 02:08 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 02/11/2025 at 01:17 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: CARRILLO HERNANDEZ, TANYA
FACILITY NUMBER: 434417657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives 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 Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Child 1 and 2 are missing LIC995 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
1
2
3
4
Licensee will submit LIC995 for child 1 and 2 to CCLD by POC date.

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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 02/11/2025 02:08 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 02/11/2025 at 01:17 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: CARRILLO HERNANDEZ, TANYA
FACILITY NUMBER: 434417657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Licensee stated she did not have a Safe Sleep log for infant in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
1
2
3
4
Licensee will begin to log infants sleep and submit a log beginning 02/12/2025 through 02/24/2025 to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
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