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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430706089
Report Date: 10/23/2023
Date Signed: 10/23/2023 11:00:18 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 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
09/22/2023 and conducted by Evaluator Ashley Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230922115242
FACILITY NAME:CAMPBELL CHRISTIAN EARLY CHILDHOOD CENTERFACILITY NUMBER:
430706089
ADMINISTRATOR:KATHY HARMONFACILITY TYPE:
850
ADDRESS:1075 WEST CAMPBELL AVE.TELEPHONE:
(408) 370-4900
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:116CENSUS: 70DATE:
10/23/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Erin KnickerbockerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility failed to report incident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Lopez conducted an unannounced follow up complaint investigation for the above allegation. LPA met with Assistant Director Erin Knickerbocker and Director Kathy Harmon and explained the reason for the visit.

During today's investigation, LPA interviewed director and reviewed pertinent documents. An unusual incident was brought to the attention of the director on 5/24/23, and they had failed to report and submit an Unusual Incident Report (LIC 624) to Community Care Licensing. Based on the information obtained, the above allegation is found to be SUBSTANTIATED, meaning the allegation is valid because the preponderance of the evidence standard has been met.
-----------------------------------continued on 9099-C----------------------------------------
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Ashley Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
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 5
Control Number 07-CC-20230922115242
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CAMPBELL CHRISTIAN EARLY CHILDHOOD CENTER
FACILITY NUMBER: 430706089
VISIT DATE: 10/23/2023
NARRATIVE
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As a result of this inspection, a type B citation was issued. Exit interview conducted and report was reviewed with Assistant Director Erin Knickerbocker.

California Code of Regulations (Title 22, Division 12) are being cited on attached LIC9099-D.

A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Ashley Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 07-CC-20230922115242
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CAMPBELL CHRISTIAN EARLY CHILDHOOD CENTER
FACILITY NUMBER: 430706089
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2023
Section Cited
CCR
101212(d)
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Reporting Requirements - Upon the occurrence, during the operation of the childcare center of any of the events specified in (d)(1), a report shall be made to the Department by telephone or fax within the Department's next working day...In addition, a written report containing the information specified in (d)(2) shall be submitted to the Department within seven days following the occurrence of such event.
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The facility had submitted a written plan to CCL on 8/11/23 to ensure that any unusual incidents shall be reported to CCL within the next business day and followed by a written report within seven days.
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This requirement was not met as evidenced by: The Director failed to report an unusual incident to Community Care Licensing (CCL) within the required time frame. This poses a potential risk to the health, safety, and personal rights of children in care.
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Facility had been cited for this regulation on 8/11/23.
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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: Joel Segura
LICENSING EVALUATOR NAME: Ashley Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5