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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434415899
Report Date: 02/03/2023
Date Signed: 02/03/2023 12:57:51 PM

Substantiated


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
10/04/2022 and conducted by Evaluator Teodoro Trujillo
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20221004083758
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: DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Hermita Ana Lazo SamaniegoTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Uncleared person in the home
parents not provided with reports/documents as required under AB633
INVESTIGATION FINDINGS:
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On 2/3/20232 at 09:34 AM, Licensing Program Analysts (LPAs) Teodoro Trujillo and Susy Cervantes met with licensee, Hermita Ana Lazo Samaniego, for a follow up complaint visit and to deliver findings. Present were licensee, licensee's adult daughter with 4 preschool age children in care.

LPAs requested a copy of the children's roster and took pictures of children's files. Based on LPAs observations, record reviews, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
LPA Trujillo and LPA Cervantes informed licensee Hermita Lazo Samaniego that this report dated 2/3/2023 documents 2(two) 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 Trujillo and LPA Cervantes informed the licensee Hermita Lazo Samaniego to provide a copy of this licensing report dated 2/3/2023 that documents any Type A citations to parents/guardians of all children currently enrolled by the next 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.

Notice of site visit was issued and must be posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 07-CC-20221004083758
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2023
Section Cited
CCR
102370(d)
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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
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Licensee will submit a written statement to the San Jose Regional office by the close of business on 02/06/2023 that she understands the requirement to have adults working, residing or volunteering at the child care home need to be fingerprint cleared.
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This requirement was not met as evidenced by, based on record review, and interviews, licensee's nephew, Diego Medrano, was not fingerprint cleared and was helping out at the child care home while licensee was out for an extended period of time.
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Type A
02/06/2023
Section Cited
HSC
1596.8595(c)
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Posting licensing report by child care facility or home; duration of posting; civil penalty for failure to comply; reports to be provided to parents or guardian of each child receiving services
A licensed child care facility or home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as specified in paragraph (1) of subdivision (a) of Section 1596.893b.
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Licensee will submit a written statement to the San Jose Regional Office by close of business on 02/06/2023 that she understands the requirement to provide any Type A reports, charges or office meeting with managers and have LIC 9224 signed within the next day or the next day child attends child care home.
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This requirement was not met as evidenced by, based on record review, and interviews, licensee did not provide Type A reports, charges or office meeting with managers in a timely manner or at all to at least 2 sets of parents.
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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.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
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