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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700549
Report Date: 05/07/2024
Date Signed: 05/09/2024 04:00:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2024 and conducted by Evaluator Anna Morales
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240506094152
FACILITY NAME:SAN JOSE DAY NURSERYFACILITY NUMBER:
430700549
ADMINISTRATOR:ELENA JOLLYFACILITY TYPE:
850
ADDRESS:33 NORTH 8TH STREETTELEPHONE:
(408) 288-9667
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:88CENSUS: 52DATE:
05/07/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Angela GomezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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1. Staff left child in the bathroom unsupervised
INVESTIGATION FINDINGS:
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Licensing Program Analysts(LPA's) Anna Morales and Andrea Cortez conducted an intial Complaint Inspection. LPA's were greeted by Executive Director Angela Gomez.

LPA's conducted interviews with staff, observed the playground bathroom, and obtained copies of pertinet information. LPA's,also, observed video footage for May 3,2024.

Based on interviewes, on May 3, 2024, at approximately at 10:08am, Staff left child(C1) unsupervised in the playground bathroom for approximately three.

(LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
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
Control Number 07-CC-20240506094152
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SAN JOSE DAY NURSERY
FACILITY NUMBER: 430700549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2024
Section Cited
CCR
101229(a)(1)
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Responsibility for Providing Care and Supervision(a)(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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 Director stated that she will submit a plan to ensure that children are supervised at all times by the POC date. This is a zero-tolerance violation and a repeat violation made within 12 months and an immediate civil penalty of $1,000.00 was assessed during the
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This requirement was not met as evidenced by: A child was left unattended in the bathroom located in the outside playground on May 3,2024.This is a zero tolerance violation. This poses an immediate risk to the health, safety, and personal rights to children in care.
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inspection. Upon receipt, Director shall post and provide copies of this licensing report, have LIC 9224 signed and kept on file, to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months & copy of the signed acknowledgment form must be kept in each child's file.
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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: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 07-CC-20240506094152
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SAN JOSE DAY NURSERY
FACILITY NUMBER: 430700549
VISIT DATE: 05/07/2024
NARRATIVE
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A Type A citation was issued at today's visit, and a copy of the Facility Evaluation Report LIC9099 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for the next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files. The citation warrants an immediate civil penalty of $1,000.00 and is hereby assessed. (This is a repeat violation from 11/17/2023). Please see LIC421IM.

Based on LPA’s observation, the preponderance of evidence standard has been met. Therefore, the above allegations are SUBSTANTIATED. An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Director. Appeal Rights Given.


A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3