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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444416000
Report Date: 10/25/2023
Date Signed: 10/25/2023 03:47:06 PM

Document Has Been Signed on 10/25/2023 03:47 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:CALDERON, KARINAFACILITY NUMBER:
444416000
ADMINISTRATOR:KARINA CALDERONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 288-0261
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
10/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Karina CalderonTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Karina Calderon for a Case Management visit. Present were licensee, licensee's sister Elvia Abrego who is her assistant and seven day care children.

During visit LPA observed a child go to an off limits area in the backyard to use the bathroom. Child opened the fence and used a potty training chair. Licensee came out and to ask child what they were doing. Child stated going to the bathroom. Based on interview conducted with child, licensee uses back part of the home that is off limits for bathroom use with a potty training chair.

The following type 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.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/25/2023 03:47 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/25/2023 at 03:14 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: CALDERON, KARINA
FACILITY NUMBER: 444416000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2023
Section Cited
CCR
102423(a)(2)

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To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement was not met as evidenced by licensee uses back part of the home that is off limits for bathroom use with a potty training chair.
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Licensee will submit a statement stating she will not use a potty training chair for potty trained children outdoors to CCLD by POC date.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
10/25/2023
Section Cited
CCR102416.3(a)(6)

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Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. This requirement was not met as evidenced by licensee uses back part of the home that is off limits for bathroom use with a potty training chair.
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Licensee will submit a statement stating she understands that she cannot use off limit areas of the home for day care use.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023


LIC809 (FAS) - (06/04)
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