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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444407398
Report Date: 12/06/2024
Date Signed: 12/06/2024 03:56:54 PM

Document Has Been Signed on 12/06/2024 03:56 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:ROMERO, MARIAFACILITY NUMBER:
444407398
ADMINISTRATOR/
DIRECTOR:		ROMERO, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 288-0285
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
12/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:02 PM
MET WITH:Maria RomeroTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Teodoro Trujillo conducted an unannounced case management visit. LPA met with licensee assistant Yulissa Romero and explained the purpose of today's inspection, licensee Maria Romero was not home. Licensee adult daughter was home with assistant. Licensee arrived at 1:16 PM with her 16 year old son.

During the visit LPA Trujillo observed a infant child(1) inside a play pen with a loose blanket while napping. .


As a result of today's inspection, a deficiency has been cited, see LIC809-D
Type A deficiencies were cited during today's visit. LPA Teodoro Trujillo informed licensee Maria Romero that this report dated 12/06/24 document(s) 1 (one) 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 Teodoro Trujillo informed the licensee Maria Romero to provide a copy of this licensing report dated 12/06/2024 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.

Exit interview conducted and report was reviewed with the Licensee, Maria Romero.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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 12/06/2024 03:56 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 12/06/2024 at 03:24 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: ROMERO, MARIA
FACILITY NUMBER: 444407398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2024
Section Cited
CCR
102425(b)

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102425(b) Infant Safe Sleep
Cribs or play yards shall be free from all loose articles and objects.
This requirement was not met as evidenced by:
Infant Child 1 was observed napping inside the play pen with a loose blanket during site visit, which poses an immediate risk to the health, safety, and personal rights of children in care.
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Licensee will submit a written statement of her understanding of CCR 102425(b) by close of business 12/09/24.

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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: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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