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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013419452
Report Date: 10/28/2021
Date Signed: 10/29/2021 11:59:50 AM

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
08/12/2021 and conducted by Evaluator Melanie Otsuji
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20210812091357
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: 22DATE:
10/28/2021
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Chantel BlasTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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- Staff are not meeting a child's hygiene needs.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Melanie Otsuji and Jonathan Williams arrived to the facility unannounced to conclude investigation into the above allegation. LPA was met by Weiling Ko. Director, Chantel Blas, returned from an off-site field trip around 12:00PM. Present during today's visit were 4 staff members and 22 preschool aged children.
During the course of the investigation, LPA collected documentation and conducted interviews. Based on interviews conducted, although children are mostly potty trained in the preschool component, some children still need assistance with wiping or need additional guidance on how to properly clean themselves after using the restroom. Multiple interviews stated that there have been occasions when their child would have redness and/or physical evidence of unhygienic practices in regards to bathroom use by children.
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: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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 3
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
08/12/2021 and conducted by Evaluator Melanie Otsuji
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20210812091357

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: 22DATE:
10/28/2021
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Chantel BlasTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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9
- Daycare children going to the bathroom unsupervised.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Melanie Otsuji and Jonathan Williams arrived to the facility unannounced to conclude investigation into the above allegation. LPA was met by Weiling Ko. Director, Chantel Blas, returned from an off-site field trip around 12:00PM. Present during today's visit were 3 staff members and 22 preschool aged children.

During the course of the investigation, LPA collected documentation and conducted interviews. Based on interviews conducted, LPAs received conflicting information regarding daycare children going to the bathroom unsupervised. Based on interviews conducted, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

A notice of site visit was given and must remain posted for 30 days.
Appeal Rights were given and discussed. An exit interview was conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 52-CC-20210812091357
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: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited
CCR
101223(a)(2)
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Personal Rights. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

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Director is to create a plan and train staff on how to properly assist children while using the bathroom. Plan of topics discussed as well as signatures of attendees to be submitted to LPA no later than 11/12/2021.
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This requirement is not being met as evidence by: Multiple interviews stated that there have been occasions when their child would have redness and/or physical evidence of unhygienic practices in regards to bathroom use by children. This poses a potential health & 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: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3