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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710174
Report Date: 06/14/2023
Date Signed: 06/14/2023 12:46:49 PM

Document Has Been Signed on 06/14/2023 12:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:DE ANZA COLLEGE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
430710174
ADMINISTRATOR:NAOKO NANCY HARADAFACILITY TYPE:
850
ADDRESS:21250 STEVENS CREEK BLVD.TELEPHONE:
(408) 864-5795
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 217TOTAL ENROLLED CHILDREN: 217CENSUS: 56DATE:
06/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Naoko Harada & Sam BlissTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico met with Dean of Community Education, Sam Bliss, and Director, Naoko Harada, and conducted a Case Management Inspection in response to an unusual incident report that was received by Community Care Licensing (CCL) on June 7, 2023. Naoko failed to report the alleged incident to CCL within the required time frame. The alleged incident is under investigation.

As a result of this inspection, deficiency was cited on the following page.

Exit interview conducted and report was reviewed with Dean of Community Education, Sam Bliss.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2023 12:46 PM - It Cannot Be Edited


Created By: Marilou Monico On 06/14/2023 at 11:17 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: DE ANZA COLLEGE CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 430710174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2023
Section Cited
CCR
101212(d)(1)&(2)

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Reporting Requirements - Upon the occurrence, during the operation of the child care 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 and during its normal business hours. 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 will submit a written plan to CCL by 06/21/23 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 alleged 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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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
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