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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434401958
Report Date: 08/11/2023
Date Signed: 08/11/2023 10:40:21 AM

Document Has Been Signed on 08/11/2023 10:40 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ARGUELLES, BERTHAFACILITY NUMBER:
434401958
ADMINISTRATOR:ARGUELLES, BERTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 243-8267
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
08/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bertha ArguellesTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo met with Bertha Arguelles, licensee, in a case management inspection with the purpose of obtaining the signature on the form LIC421BG.
LPA observed licensee was providing care and supervision to seven children, including four preschoolers and three infants. Licensee's helper Gloria Garcia was present in the home as well.

No deficiencies were cited today.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023
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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