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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410917
Report Date: 11/03/2023
Date Signed: 11/03/2023 10:57:55 AM

Document Has Been Signed on 11/03/2023 10:57 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:AGUSTIN, DEOTINAFACILITY NUMBER:
434410917
ADMINISTRATOR:DEOTINA AGUSTINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 258-1944
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 12DATE:
11/03/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Deotina AgustinTIME COMPLETED:
11:28 AM
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Licensing Program Analyst (LPA), Janette Cruz, conducted an unannounced case management inspection and met with Licensee, Deotina Agustin. LPA explained to Licensee that purpose of today's inspection was to verify completion of the plans of correction resulted from previous complaint inspection completed on 10/27/23.

LPA toured indoor and outdoor areas of the home. LPA observed twelve children (four infants, eight preschool) and Licensee's adult assistants (Tham Nguyen, Gloria Mora & Ximena Capetillo Buenro) present during today's inspection. LPA reviewed children's files and observed signed LIC9224 Acknowledgement of Receipt of Licensing Reports in all children's files.

The Licensee was issued one "Type A" deficiency on 10/27/23 as a result of a substantiated complaint investigation. The deficiency was issued under Health and Safety Code section 1597.465(a)(b) Large family day care homes; number of children.
The Licensee submitted a written Plan of Correction to LPA Cruz in which she indicates that she understands the required capacity/ratio for her large Family Child Care Home License. The Licensee states that she understands the conditions to be met for providing care for more than 12 children in a large family child care home. Licensee provided LPA the record of children's attendance from Oct 30 - Nov 2, 2023. LPA observed that the facility was in compliance with staff to children ratio/capacity from 11/1/23 up to today's inspection.

Civil penalty was issued during today's inspection for failure to correct the violation cited on 10/27/23 under HSC 1597.465 (a)(b) based on children's attendance reviewed for Oct. 30-31, 2023. Exit interview conducted and reviewed with Deotina Agustin, Licensee.

Notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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