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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409522
Report Date: 05/21/2024
Date Signed: 07/23/2024 09:27:16 AM

Document Has Been Signed on 07/23/2024 09:27 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:HERNANDEZ, GLADYSFACILITY NUMBER:
073409522
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
05/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:28 PM
MET WITH:Karla Urquilla & Gladys HernandezTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On May 21, 2024 Licensing Program Analyst Indira Loza met with Assistant Karla Urquilla for another matter. LPA toured the home for a Health and Safety Check. Present during the visit were the Licensee's elderly mother, Licensee's sister Ana Hernandez, Assistant Karla Urquilla, two school-age children, 4 preschoolers, and two infants. The Licensee arrived about 25 minutes after LPA Loza arrived.

There were no deficiencies cited during today's visit.

Exit interview conducted.
Report and Appeal Rights provided to Licensee Gladys Hernandez.
Notice of Site visit must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document is an Amendment of Original Document on 06/25/2024 04:08 PM


Created By: Indira Loza On 05/21/2024 at 04:29 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HERNANDEZ, GLADYS
FACILITY NUMBER: 073409522

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)

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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2