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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013419494
Report Date: 11/18/2021
Date Signed: 11/18/2021 01:25:11 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
09/13/2021 and conducted by Evaluator Melanie Otsuji
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20210913161203
FACILITY NAME:PALM ACADEMYFACILITY NUMBER:
013419494
ADMINISTRATOR:YEN NGUYENFACILITY TYPE:
840
ADDRESS:2856 WASHINGTON BLVDTELEPHONE:
(510) 979-9794
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:72CENSUS: 2DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Chantel BlasTIME COMPLETED:
01:44 PM
ALLEGATION(S):
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- Staff did not prevent children from engaging in physical altercations.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Melanie Otsuji arrived to the facility unannounced to conclude investigation into the above allegation. LPA was met by Director Chantel Blas. Present during today's visit was 1 staff member and 2 school aged children.

During the course of the investigation LPA collected documentation and conducted interviews. Based on interviews it was determined that there have been multiple incidents of children hitting other children. Although staff were present during these incidents, staff did not provide the adequate supervision to prevent the continual incidents from happening. 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: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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-20210913161203
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: 013419494
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2021
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 previously conducted an all staff training due to citation within preschool component. Director is to provide a written statement indicating what day the training was provided along with topics and staff signatures of those who attended that training. Written statement to be submitted to LPA no later than 12/2/2021.
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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/hurting other children. 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: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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
09/13/2021 and conducted by Evaluator Melanie Otsuji
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20210913161203

FACILITY NAME:PALM ACADEMYFACILITY NUMBER:
013419494
ADMINISTRATOR:YEN NGUYENFACILITY TYPE:
840
ADDRESS:2856 WASHINGTON BLVDTELEPHONE:
(510) 979-9794
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:72CENSUS: 2DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Chantel BlasTIME COMPLETED:
01:44 PM
ALLEGATION(S):
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- Staff handled child in a rough manner.
- Staff inappropriately punished day care child.
- Staff used inappropriate language with day care child.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Melanie Otsuji arrived to the facility unannounced to conclude investigation into the above allegation. LPA was met by Director Chantel Blas. Present during today's visit was 1 staff member and 2 school 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4