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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434415899
Report Date: 02/11/2022
Date Signed: 02/11/2022 10:24:56 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2021 and conducted by Evaluator Deanna Villagrana
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20211215134618
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:14CENSUS: 4DATE:
02/11/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hermita Ana Lazo SamaniegoTIME COMPLETED:
09:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Daycare child was locked in a closet for extended period of time
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Deanna Villagrana and Teodoro Trujillo met with licensee Hermita Ana Lazo Samaniego to deliver findings for above allegation. Present in the home was licensee, licensee's assistant Shirley Rodriguez and four day care children.

Based on pertinent information obtained from Investigation Bureau, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiency was cited.

Notice of Site was issued and must be posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
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