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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406608
Report Date: 07/30/2025
Date Signed: 07/30/2025 04:23:23 PM

Document Has Been Signed on 07/30/2025 04:23 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:CHAGOLLA, ELBAFACILITY NUMBER:
434406608
ADMINISTRATOR/
DIRECTOR:		CHAGOLLA, ELBAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 942-8782
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 14DATE:
07/30/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Licensee Elba ChagollaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 7/30/2025 at 2:30 pm, Licensing Program Analyst (LPA) Manel Estoesta conducted an Annual / Random Visit. LPA met with the Licensee Elba Chagolla and explained the nature of the site visit. Present for this visit were Licensee’s Assistant Provider (Licensee’s Adult Son), Licensee's Spouse, 2 infants, 10 preschool children and 2 school age children. The home currently operates from Monday to Friday from 7 am to 6 pm.

The home was toured to conduct a Health and Safety Inspection. The home is a one-story home. The home is neat and clean with heating and ventilation for safety and comfort.

The On Limit Areas the Day Care Playroom, hallway bathroom, dining room, family room and backyard. The Backyard play area is completely fenced.

The Off Limit Areas two bedrooms, master bedroom, master bath, kitchen and the Garage which will be inaccessible by closed and or locked doors and or a fence with visual supervision.

The Isolation Area will be the family room. There are ample age-appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs, or any other bodies of water present during today's inspection. All hazardous materials and toxins are kept out of the reach of children, and it was observed that there are no toxins or hazardous items accessible today.

The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills at least twice a year with the last one conducted on 7/17/2025. Licensee owns the house and has childcare liability insurance.

NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Manel Estoesta
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2025
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CHAGOLLA, ELBA
FACILITY NUMBER: 434406608
VISIT DATE: 07/30/2025
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The licensee CPR and First Aid certificate expires on 03/16/2026. Licensee and Licensee's Assistant have current Mandated Reporter Training Certificates. Licensee and Licensee's Assistant have records of Measles and Pertussis immunization, Influenza vaccination and TB clearance. LPA reminded Licensee that only the Influenza vaccination can be decline with a written declination.

LPA reviewed the Facility roster of children. LPA reviewed the Children’s files, which included records of receipt for Parents' Rights Notice, Identification and Emergency Information, Consent for Emergency Medical Treatment form, LIC 9150, Sleep Logs, LIC 282, and Immunization. The licensee is in ratio today. Licensee stated that she does not transport children at this time. The home has a pet dog at home and has a current on his vaccination record.

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-and-resources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

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.

NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Manel Estoesta
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CHAGOLLA, ELBA
FACILITY NUMBER: 434406608
VISIT DATE: 07/30/2025
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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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

There are no deficiencies cited on this visit.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Elba Chagolla.

NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Manel Estoesta
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC809 (FAS) - (06/04)
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