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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444413610
Report Date: 11/30/2021
Date Signed: 07/13/2022 03:33:17 PM

Document Has Been Signed on 07/13/2022 03:33 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:COVARRUBIAS, OLIVIAFACILITY NUMBER:
444413610
ADMINISTRATOR:COVARRUBIAS, OLIVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 786-6777
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
11/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Olivia Covarrubias TIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Berumen met with Olivia Covarrubias for a case management visit. LPA observed Licensee, Olivia Covarrubias alone with 8 day-care children, one infant, and 7 pre-schoolers. Licensee states that her daughter/Assistant should arrive soon; she states that her daughter had a Dr. Appt in Santa Cruz today.

Licensee is operating out of ratio today. If no assistant provider is present at a large family child care home, then the licensee shall comply with the capacity requirements for a Small Family Child Care home.

deficiency cited on 809D.
NOTICE OF SITE VISIT WAS ISSUED AND SHALL REMAIN POSTED FOR 30 DAYS ALONG SIDE TYPE A DEFICIENCY.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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 07/13/2022 03:33 PM - It Cannot Be Edited


Created By: Elizabeth Berumen On 11/30/2021 at 11:05 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: COVARRUBIAS, OLIVIA
FACILITY NUMBER: 444413610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2021
Section Cited
CCR
102416.5(e)

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Staffing Ration & Capacity
If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).
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Licensee is to submit a written plan of correction stating, she understands section 102416.5. She is also to state what she will do when she does not have an assistant to follow the ratio and capacity options.
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This requirement was not met as evidenced by: LPA observed 1 infant and 7 preschool children in care with Licensee. No assistant.
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Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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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:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021


LIC809 (FAS) - (06/04)
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