<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415187
Report Date: 07/29/2022
Date Signed: 07/29/2022 04:09:05 PM

Document Has Been Signed on 07/29/2022 04:09 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MACHUCA, ROMELIAFACILITY NUMBER:
434415187
ADMINISTRATOR:MACHUCA, ROMELIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 842-6907
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
07/29/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Romelia MachucaTIME COMPLETED:
01:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management- Licensee Initiated. LPA met with Licensee Romelia Machuca and explained the reason for the inspection. The purpose of this inspection is Licensee is requesting to make the bedroom on the left side of the front door to on-limits. Present during today's inspection were Licensee, her two adult daughters, her mother, and 5 children.

During today's inspection, LPA inspected the bedroom. LPA observed that the room is safe for the children. An updated LIC 999A was obtained during today's inspection. The off-limit areas of the home inside are Room 2, Room 3, Room 4, and the restroom. Fire clearance was granted on 12/11/2018.

LPA observed that there was a baby bouncer outside. Licensee stated that they use it for the dolls. She stated that she will remove the baby bouncer. LPA also observed that there was bucket of paint and cleaning spray for the car outside in the covered garage. Licensee moved the bucket of paint and cleaning spray to a off-limit area.

No deficiencies were issued. Exit interview conducted and report was reviewed with the licensee Romelia Machuca. 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.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1