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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415939
Report Date: 04/26/2024
Date Signed: 08/06/2024 03:28:10 PM

Document Has Been Signed on 08/06/2024 03:28 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:VASQUEZ, LORENAFACILITY NUMBER:
444415939
ADMINISTRATOR/
DIRECTOR:		LORENA VASQUEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 247-8372
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
04/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:48 PM
MET WITH:Lorena VasquezTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teodoro Trujillo met with Lorena Vasquez and explained the nature of visit to her. Present were adults, Alma,and licensee's 17 year old daughter with 3 children in care: two (2) infants, one (1) preschool age, three (3) school age children arrived during site visit..

LPA conducted a case management visit to amend reports from 11/08/24 and 12/08/24 site visits. During today's sit visit, LPA observed the sleep logs were not being documented for the two infants in care. Licensee stated she had not completed the sleep logs for the three months that are missing. LPA took photos of logs, Jan 2024, Feb 20024 and April 2024 15 minute sleep logs were not done.

Type B Deficiencies were cited today. Licensee 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 conducted and report was reviewed with the Licensee, Lorena Vasquez.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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 08/06/2024 03:28 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 04/26/2024 at 01:09 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: VASQUEZ, LORENA
FACILITY NUMBER: 444415939

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2024
Section Cited
HSC
102425(j)(2)(D)

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Infant Safe Sleep
Based on observation, interview, and record review, the licensee did not comply with the section cited above, two infants in care had missing sleep logs for, Jan 2024, Feb 2024 and April 2024, which poses a potential health, safety or personal rights risk to persons in care.
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Licensee will begin documenting the infant sleep and will submit completed sleep logs to the San Jose Regional office, starting with 4/26/24 to 5/03/2024.
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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: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
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