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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440702549
Report Date: 05/01/2023
Date Signed: 05/01/2023 01:40:28 PM

Document Has Been Signed on 05/01/2023 01:40 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:CABRILLO COLLEGE CHILDREN'S CENTERFACILITY NUMBER:
440702549
ADMINISTRATOR:TRICIA PASTOR CROSSFACILITY TYPE:
850
ADDRESS:6500 SOQUEL DRIVETELEPHONE:
(831) 479-6352
CITY:APTOSSTATE: CAZIP CODE:
95003
CAPACITY: 37TOTAL ENROLLED CHILDREN: 37CENSUS: 12DATE:
05/01/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tricia PastorTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Larios conducted an unannounced Case Management - Annual Continuation. The purpose of today’s visit is to conduct staff interview and finish tool inspection. LPA met with the Director Tricia Pastor & Administrative Assistant Lisa Hirahara and explained the nature of today's visit.

Exit interview conducted and report was reviewed with the Director Tricia Pastor. Deficiency issued during today's inspection and appeal rights were given.



A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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 2
Document Has Been Signed on 05/01/2023 01:40 PM - It Cannot Be Edited


Created By: Elizabeth Larios On 05/01/2023 at 11:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CABRILLO COLLEGE CHILDREN'S CENTER
FACILITY NUMBER: 440702549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101170(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record reviews, the licensee did not comply with the section cited above staff (S-1 & S-1) is not associated to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2023
Plan of Correction
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Director agreed to submit a transfer request for staff (S-1) by POC date to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Joel Segura
LICENSING EVALUATOR NAME:Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2