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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430709991
Report Date: 03/17/2025
Date Signed: 03/17/2025 03:06:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 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
03/11/2025 and conducted by Evaluator Jialing Zhu
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20250311085548
FACILITY NAME:ADDISON KID'S CLUBFACILITY NUMBER:
430709991
ADMINISTRATOR:BARAJAS, JORGEFACILITY TYPE:
840
ADDRESS:650 ADDISON AVE.TELEPHONE:
(650) 323-4007
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:70CENSUS: 0DATE:
03/17/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jorge BarajasTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are forging parent signatures on sign in/sign out records.
INVESTIGATION FINDINGS:
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On 03/17/2025 at 12:45pm, Licensing Program Analyst (LPA) Jialing “Julianne” Zhu conducted an UNANNOUNCED COMPLAINT SITE INSPECTION. LPA met with Director Jorge Barajas. LPA advised director of the nature of the inspection. A complaint regarding Other – Overall Operations was filed against the facility. LPA and director toured the facility for health and safety inspection. Present during the inspection were one (1) fingerprint-cleared staff and 0 children in care.
LPA confirmed with director the Facility Roster and Personnel Report obtained on 01/13/2025 is still current as of today’s inspection. LPA requested a sample of the sign-in/out record and a sample of children’s files. LPA conducted interview with director. Based on LPA’s observations, record review, and director interview, the preponderance of evidence standard has been met as a sample of parent signatures on the sign-in/out sheets do not match, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 12, 101229.1(b) is being cited on the attached LIC 9099D.
Notice of Site Visit was given and must remain posted for 30 days. Report was reviewed, exit interview was conducted, and Appeal Rights were provided to Director Jorge Barajas.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
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 2
Control Number 52-CC-20250311085548
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: ADDISON KID'S CLUB
FACILITY NUMBER: 430709991
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2025
Section Cited
CCR
101229.1(b)
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101229.1 Sign In and Sign Out (b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.

This requirement is not met as evidenced by:
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Director will email to LPA a written statement that indicates the staff responsible for signing the children out for the day and the procedure(s) for handling situations when parents forget to sign-out.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as a sample of parent signatures on sign-in/out sheets do not match, which poses potential health, safety, and/or personal rights risk to persons in care.
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Director will email written statement to LPA at jialing.zhu@dss.ca.gov by 04/17/2025.
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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: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC9099 (FAS) - (06/04)
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