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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013419452
Report Date: 05/14/2024
Date Signed: 05/14/2024 01:48:17 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
03/07/2024 and conducted by Evaluator Melanie Otsuji
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20240307133605
FACILITY NAME:PALM ACADEMYFACILITY NUMBER:
013419452
ADMINISTRATOR:YAO, LIPINGFACILITY TYPE:
850
ADDRESS:2856 WASHINGTON BLVD.TELEPHONE:
(510) 979-9794
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:59CENSUS: 44DATE:
05/14/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Liping YaoTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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- Licensee did not adhere to Admission Agreement requirements.
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 met with Director, Liping Yao. Also present during today's visit were, 7 additional staff members and 44 preschool aged children.

During the course of the investigation, LPA conducted record reviews, made observations and conducted interviews. Based on interviews it was stated that some parents were not given a copy of the admission agreement and terms of the admission agreement changed without the required 30 day notification. 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, Liping Yao.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 52-CC-20240307133605
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: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
101219(f)
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Admission Agreement. The licensee shall comply with all terms and conditions set forth in the admission agreement.

This requirement is not being met as evidence by: multiple interviews stated that licensee changed terms of the admission
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Licensee is to ensure that all authorized representatives receive a signed copy of the admission agreement. Licensee is to provide a signed written statement that Licensee understands and agrees to follow Title 22 Section 101219. Signed statement to be submitted via email to LPA no later than
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agreement without the required 30 day notification. This poses a potential health & safety risk to children in care.
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5/24/2024.
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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: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
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