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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415899
Report Date: 04/05/2022
Date Signed: 04/05/2022 04:15:02 PM

Document Has Been Signed on 04/05/2022 04:15 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: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: 19CENSUS: 14DATE:
04/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Hermita Ana Lazo SamaniegoTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Deanna Villagrana and Teodoro Trujillo met with licensee Hermita Ana Lazo Samaniego for an announced case management visit. Present were licensee, licensee's assistants Shirley Rodriguez and Guiselle Ruiz with 14 children. LPA's observed one kindergartner, eight children between the ages of 2 and 5 and five infants. Facility is out of ratio.

LPA observed child 11 was missing from the roster. This is a repeat violation from report on 12/02/2021. Licensee's assistant Guiselle Ruiz did not have LIC508 in file. This is a repeat violation for report dated on 03/02/2022. Mother of child 15 arrived to find her son was not at facility. Licensee admitted to mother that she took her child to another provider's home. Licensee went to pick up child and mother followed her to pick him up herself. Mother did not give permission for child to be sent to another facility. Licensee made false statement to LPAs that child 15 did not attend facility today when mother states she did in fact dropped of the child with Hermita this morning.

The following type A and 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.

LPAs Deanna Villagrana and Teodoro Trujillo informed licensee Hermita Ana Lazo Samaniego that this report dated 04/05/2022 document(s) 3 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 Deanna Villagrana and Teodoro Trujillo informed the licensee Hermita Ana Lazo Samaniego to provide a copy of this licensing report dated 04/05/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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 04/05/2022 04:15 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 04/05/2022 at 01:15 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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2022
Section Cited
CCR
102416.5(d)(1)

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Twelve children, no more than four of whom may be infants.
This requirement was not met as evidenced by LPA's observed one kindergartner, eight toddlers and five infants. Facility is out of ratio.
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Licensee will cease operating out of ratio immediately. Licensee was made aware that she is required to attend a Non-compliance meeting when schedule at the San Jose Regional office.
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This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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Type A
04/05/2022
Section Cited
CCR102423(a)(2)

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Each child shall be accorded safe, healthful and comfortable accommodations, furnishing and equipment. This requirement was not met as evidenced by LPAs were made aware a child was dropped off at the facility and taken to another provider's home. Mother of child 15 arrived to find her son was not at facility.
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Licensee was made aware that she is required to attend a Non-Compliance meeting when schedule at the San Jose Regional office.
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Licensee went to pick up child and mother followed her to pick him up herself. Mother did not give permission for child to be sent to the other facility.
This poses an immediate risk to the Health, Safety or Personal Rights 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: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/05/2022 04:15 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 04/05/2022 at 01:35 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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2022
Section Cited
CCR
102417(g)(8)

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met as evidenced by LPA observed child 11 was missing from the roster.
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Licensee completed roster during visit. Deficiency cleared today.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
04/12/2022
Section Cited
CCR102416.1(a)(11)

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Personnel records shall contain a signed statement regarding their criminal record history, and shall contain specified information. This requirement was not met as evidenced by
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Licensee will submit LIC508 for assistant to CCLD by POC date.
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Licensee's assistant Guiselle Ruiz did not have LIC508 in file. 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: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/05/2022 04:15 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 04/05/2022 at 03:49 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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2022
Section Cited
HSC
1569.58(a)(1)

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Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California. This requirement was not met as evidenced by Licensee made
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Licensee was made aware that she is required to attend a Non-Compliance meeting when schedule at the San Jose Regional office.
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false statement to LPAs that child 15 did not attend facility today when mother states she did in fact dropped of the child with Hermita this morning. This poses an immediate risk to the Health, Safety or Personal Rights 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: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ANA
FACILITY NUMBER: 434415899
VISIT DATE: 04/05/2022
NARRATIVE
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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.

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: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC809 (FAS) - (06/04)
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