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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274417590
Report Date: 05/28/2025
Date Signed: 05/28/2025 03:36:28 PM

Document Has Been Signed on 05/28/2025 03:36 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:IBARRA, LETICIAFACILITY NUMBER:
274417590
ADMINISTRATOR/
DIRECTOR:		LETICIA IBARRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 206-4584
CITY:SOLEDADSTATE: CAZIP CODE:
93960
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
05/28/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Leticia IbarraTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analysts (LPA) Martha Jimenez-Villanueva met with licensee Leticia Ibarra for an unannounced annual inspection. LPA explained the nature of today’s inspection. Licensee and her mom/helper were present with (8) eight day-care children: 2 infants and 6 toddlers. All required posting materials were posted. Licensee s stated days and hours of operation are Monday to Saturday from 5:00AM to 6:00PM. Per licensee, adults residing in the home are licensee, her husband, her daughter and her two sons. Licensee stated her 14-year-old son is also residing in the home. LPA provided and received from licensee an updated LIC 27 during this visit. The home is a two-story home with five (5) bedrooms and two (2) complete bathrooms and half (1/2) bath.

A review of staff records on 05/28/2025 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA obtained a copy of current children's roster. Fire/disaster drill was conducted on May 5, 2025. LPA observed a fully charged 3A40BC fire extinguisher that was serviced on 05/01/2025, functioning smoke and carbon monoxide combo detector. There are no fireplace, no wall heather and no bodies of water in the home. LPA observed stairs are gated inside the home. There is a dog, licensee stated dog is vaccinated and stayed outside of the home in off area limits. The backyard is fenced.

Report continues in next pages.
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Martha Jimenez-Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: IBARRA, LETICIA
FACILITY NUMBER: 274417590
VISIT DATE: 05/28/2025
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LPA toured the indoor and outdoor areas of the home with the Licensee during today's inspection. Off limit areas: entire second floor that has five bedrooms, two bathrooms, garage, storage room, and right side yard fenced.

The home is clean, orderly, (including heating/air conditioning and ventilation) for safety and comfort for children in care. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible to children in the garage and upstairs. LPA observed sufficient age-appropriate materials, toys, and play equipment in the the home. The children's bathroom is clean, sanitary, and operable. The home has a working telephone in the home.

LPA reviewed six (6) children's files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Infant Sleep Log (LIC 9227), sleep log (for children 0-24 months), and Immunization Records. All required forms are on file. The home has current Insurance Liability with Relation Insurance Services Select, Inc.

LPA reviewed licensee and helper’s file. Licensee and her helper have current Pediatric CPR/1st Aid with expiration date 04/27/2026 both. Licensee and her helper have Mandated Reporter training completed on 03/30/2024 and 12/06/2024 respectively. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee and helper. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

Supervision of children was discussed with licensee, and she understands that she must be present in the home during day care hours (80% of the operating hours) and ensure that the children are supervised at all times. Licensee understands her capacity options and she understand that she cannot have more than 14 children in the home at any time. Licensee stated that a child will be isolated in a corner in the 2nd living room area if necessary due to illness or communicable disease. Licensee stated that she does not transport any day care children. LPA reminded licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size and car seats shall not be used for sleeping.



Report continues in next pages.
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Martha Jimenez-Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: IBARRA, LETICIA
FACILITY NUMBER: 274417590
VISIT DATE: 05/28/2025
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee is not providing IMS currently. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Leticia Ibarra confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



No deficiencies were cited today. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Leticia Ibarra in Spanish.
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Martha Jimenez-Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
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