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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013419452
Report Date: 11/03/2022
Date Signed: 11/03/2022 12:34:14 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
09/07/2022 and conducted by Evaluator Melanie Otsuji
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20220907102146
FACILITY NAME:PALM ACADEMYFACILITY NUMBER:
013419452
ADMINISTRATOR:BLAS, CHANTELFACILITY TYPE:
850
ADDRESS:2856 WASHINGTON BLVD.TELEPHONE:
(510) 979-9794
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:59CENSUS: 22DATE:
11/03/2022
UNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Seliya YooTIME COMPLETED:
12:38 PM
ALLEGATION(S):
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- Staff did not provide adequate supervision to day-care children while in care resulting in injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melanie Otsuji arrived to the facility unannounced to conclude investigation into the above allegation. LPA was met by Director Seliya Yoo. Present during today's visit were 5 additional staff members and 22 preschool aged children.

During the course of the investigation LPA conducted record reviews, interviews and made observations. Based on the information collected, there have been multiple incidents where a child/children enrolled into the program had become aggressive towards staff and other children by throwing toys and hitting others. Based on the LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter Number 101223), are being cited on the attached LIC 9099D.

An exit interview was conducted and the report was discussed with Director, Seliya Yoo.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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-20220907102146
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: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2022
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 supervise children in care and how to prevent incidents such as hitting/throwing toys. Plan of topics discussed as well as signatures of attendees to be submitted to LPA no later than 11/28/2022.
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This requirement is not being met as evidence by: Based on interviews it was determined that there have been multiple incidents of children hitting/throwing items at other children and staff. Although staff were present during these incidents, staff did not provide the adequate supervision to prevent the continual incidents from happening. 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: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
09/07/2022 and conducted by Evaluator Melanie Otsuji
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20220907102146

FACILITY NAME:PALM ACADEMYFACILITY NUMBER:
013419452
ADMINISTRATOR:BLAS, CHANTELFACILITY TYPE:
850
ADDRESS:2856 WASHINGTON BLVD.TELEPHONE:
(510) 979-9794
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:59CENSUS: 22DATE:
11/03/2022
UNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Seliya YooTIME COMPLETED:
12:38 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff did not ensure day care was free from pests.
INVESTIGATION FINDINGS:
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5
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7
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10
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13
Licensing Program Analyst (LPA) Melanie Otsuji arrived to the facility unannounced to conclude investigation into the above allegation. LPA was met by Director Seliya Yoo. Present during today's visit were 5 additional staff members and 22 preschool aged children.

Based on interviews conducted there was conflicting information received. 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 with Director, Seliya Yoo.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4