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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415899
Report Date: 02/11/2022
Date Signed: 02/11/2022 10:25:38 AM

Document Has Been Signed on 02/11/2022 10:25 AM - 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:LAZO SAMANIEGO, HERMITA ANAFACILITY NUMBER:
434415899
ADMINISTRATOR:HERMITA ANA LAZO SAMANIEGOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 416-6916
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 14TOTAL ENROLLED CHILDREN: 16CENSUS: 4DATE:
02/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Hermita Ana Lazo SamaniegoTIME COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Deanna Villagrana and Teodoro Trujillo met with licensee Hermita Ana Lazo Samaniego for a Case Management visit. Present were licensee, licensee's assistant Shirley Rodriguez and four day care children.

LPAs tour the inside and outside of the home. LPAs observed a locked jacuzzi in the backyard. LPAs observed dog feces and urine on the artificial turf were children play. Children were not outside during observation. LPAs observed LIC9224 in children's files for report dated 12/17/2021.

The following type B deficiency was 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 was issued and must be posted for 30 days.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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 02/11/2022 10:25 AM - It Cannot Be Edited


Created By: Deanna Villagrana On 02/11/2022 at 09:53 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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2022
Section Cited
CCR
102417(b)

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The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.
This requirement was not met as evidenced by LPAs observed dog feces and urine on the artificial turf were children play.
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Licensee's assistant picked up feces immediately and cleaned area.
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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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2022


LIC809 (FAS) - (06/04)
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