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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075700205
Report Date: 03/03/2023
Date Signed: 03/03/2023 12:21:24 PM

Document Has Been Signed on 03/03/2023 12:21 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:JIMENEZ, KARINAFACILITY NUMBER:
075700205
ADMINISTRATOR:JIMENEZ, KARINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 248-3508
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
03/03/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Karina JimenezTIME COMPLETED:
12:30 PM
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On March 3, 2023 at 11:25am, Licensing Program Analyst (LPA) Julia Placencia arrived unannounced for a plan of correction (POC) inspection to confirm the facility is within its ratio/capacity limits. LPA met with licensee Karina Jimenez. Present were three infants, seven preschoolers, and helper Claudia Quiroz.

During a visit to the facility conducted on 2/22/23, LPA observed there were 13 children present (4 infants and 9 preschoolers). Upon arrival today, LPA observed 10 children (3 infants and 7 preschoolers). LPA observed signed Acknowledgement of Receipt of Licensing Reports forms (LIC 9224) in children's files.

ยง1597.465(a) Staffing Ratio and Capacity cited on 2/22/23 is cleared today. Copy of Letter of Deficiency Citations Cleared provided at visit.

Exit interview conducted with licensee Karina Jimenez. A Notice of Site Visit was provided and must remain posted for 30 days.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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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