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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013419452
Report Date: 04/05/2021
Date Signed: 04/05/2021 01:26:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2021 and conducted by Evaluator Melanie Otsuji
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20210401135333
FACILITY NAME:PALM ACADEMYFACILITY NUMBER:
013419452
ADMINISTRATOR:YEN NGUYENFACILITY TYPE:
850
ADDRESS:2856 WASHINGTON BLVD.TELEPHONE:
(510) 979-9794
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:59CENSUS: 14DATE:
04/05/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Weiling "Sophie" KoTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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- Staff are not serving food of the quality necessary to meet the needs of children.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Melanie Otsuji and Jonathan Williams arrived to the facility unannounced to conduct an initial investigation into the above allegation. LPA was met with Office Administrator, Sophie Ko. Present during today's visit were 3 preschool staff and 14 preschool aged children.

LPAs made observations and conducted interviews. Based on observations LPAs observed Go-Gurt within in a preschool classroom to have been expired. LPAs also observed expired brownie mix, crackers (best if used by dates expired), and expired string cheese within the school's pantry and refrigerator.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12 & Chapter 1), are being cited on the attached LIC. 9099D.

Exit interview conducted. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 52-CC-20210401135333
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PALM ACADEMY
FACILITY NUMBER: 013419452
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2021
Section Cited
CCR
101227(a)(1)
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101227(a)(1) Food Service. In child care centers providing meals to children, the following shall apply: All food shall be safe and of the quality and in the quantity necessary to meet the needs of the children.

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Director is to create a plan to conduct proper inventory of food with respect to expiration date. Plan to be submitted to LPA no later than 4/19/2021 via email or mail.
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This requirement has not been met as evidence by: Based on LPA observations, LPAs observed expired dairy products within the classroom and expired crackers, and brownie mix within the pantry. This has the potential to be a health and safety risk to children in care.
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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.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4