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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444406204
Report Date: 03/22/2024
Date Signed: 03/22/2024 12:46:49 PM

Document Has Been Signed on 03/22/2024 12:46 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:DA SILVA, MARTHAFACILITY NUMBER:
444406204
ADMINISTRATOR:DA SILVA, MARTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 722-1854
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
03/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Martha Da SilvaTIME COMPLETED:
12:59 PM
NARRATIVE
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On 3/22/24 Licensing Program Analyst (LPA) Teodoro Trujillo conducted an unannounced Case Management visit to deliver amended reports from 11/03/23 site visit. LPA met with licensee, Martha Da Silva. Present were the licensee, licensee adult son, Daniel and assistant Luz with Seven (7) children: one (1) infant, six(6) preschool age.

Based on file reviews, three Infants from the 11/03/23 site visit did not have the 15 min safe sleep check logs started: C1, C2, and C3 missing sleep logs.

Type B Deficiency was cited today for the 11/03/23 site visit. Licensee, Martha was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.



Exit interview was conducted and report was reviewed with Martha Da Silva.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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 03/22/2024 12:46 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 03/22/2024 at 11:47 AM
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: DA SILVA, MARTHA
FACILITY NUMBER: 444406204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2024
Section Cited
CCR
102425(j)(2)(D)

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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:
A. Date.
B. Infant’s name.
C. Time of each 15-minute check.
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Licensee provided copies of Infant sleep logs for the 3 infants in care from the 11/03/23 site visit and provided a written statement to the San Jose Regional Office on 11/17/23 on her understanding of CCR 102425 regulation.
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This requirement is not met as evidenced by: Based on record review, and interview the licensee did not comply with the section cited above, on 11/03/23 site visit the 15-Minute sleep logs had not been started for Child 1, C2 and C3, which posed an potential health, safety or personal rights risk to persons in care.

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Deficiency cleared.

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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:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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