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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070213499
Report Date: 08/26/2025
Date Signed: 08/26/2025 04:25:54 PM

Document Has Been Signed on 08/26/2025 04:25 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:ELIZALDE, MIRTHAFACILITY NUMBER:
070213499
ADMINISTRATOR/
DIRECTOR:		ELIZALDE, MIRTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 285-6161
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 12TOTAL ENROLLED CHILDREN: 2CENSUS: 1DATE:
08/26/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Mirtha ElizaldeTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jaleesa Jackson conducted an unannounced Case Management inspection and met with Licensee Mirtha Elizalde. The purpose of the inspection was to ensure compliance with AB2866 pool safety requirements. There was 1 preschool aged child present during today's inspection.

LPA observed licensee's pool to be fully enclosed by use of a mesh fence. The mesh fence has a self closing/latching gate that opens away from the pool. The fence does not obstruct the view of the pool. Licensee has a pool alarm but the batteries were not installed. Licensee stated she is getting batteries right away to be in compliance. She stated when she purchased it she originally thought it came with batteries. Licensee has a life ring with a 19 inch diameter that is labeled that it is approved by the United States Coast Guard. Licensee does have a rescue pole however the pole is adjustable and not a fixed length as required. Licensee stated she thought the pole she purchased was the right one and was unaware that it was the wrong type. She stated she will purchase the correct one right away and it was not purposeful she thought all the items purchased for the pool were correct. The backyard pool area is off limits with a second metal gate to prevent access by children.

See 809-D for deficiencies cited today.

Notice of Site Visit was provided and must be posted for 30 days.

Exit interview and report reviewed with Mirtha Elizalde.

NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Jaleesa Jackson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/26/2025 04:25 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 08/26/2025 at 03:18 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ELIZALDE, MIRTHA
FACILITY NUMBER: 070213499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2025
Section Cited
CCR
1596.814(a)(1)(B)

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An alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water. The alarm shall be turned on and be in working condition during a facility’s operating hours while the swimming pool is not in use.
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Licensee will install pool alarm with batteries a plan of correction visit will be made to verifiy the alarm is functional.
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Based on observation, the licensee did not comply with the section cited above in the licensee does not have a functional pool alarm which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/26/2025
Section Cited
CCR1596.814(a)(2)(B)

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The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use:
A rescue pole with a body hook and a minimum fixed length of 12 feet.
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Licensee will purchase a fixed length 12 foot rescue pole with a body hook for the in ground pool area by POC date and submit proof to LPA by email.
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Based on observation, the licensee did not comply with the section cited above in the licensee does not have a 12 foot fixed length rescue pole with hook which poses/posed a potential health, safety or personal rights risk to persons 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.
Jason Jang
NAME OF LICENSING PROGRAM MANAGER:
Jaleesa Jackson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2025


LIC809 (FAS) - (06/04)
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