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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400032
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:33:25 PM

Document Has Been Signed on 05/23/2024 03:33 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CALIFORNIA YOUNG WORLD AT SAN MIGUELFACILITY NUMBER:
434400032
ADMINISTRATOR/
DIRECTOR:		EMERSON VENTURAFACILITY TYPE:
840
ADDRESS:777 SAN MIGUEL AVENUETELEPHONE:
(408) 738-1385
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 42TOTAL ENROLLED CHILDREN: 29CENSUS: 19DATE:
05/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Emerson VenturaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mel Matos met with Emerson Ventura, director, for an unannounced case management investigation. Purpose of the investigation: investigate an Unusual Injury that the Facility self reported to the Department on May 16, 2024.

The Unusual Injury occurred on Monday May 13, 2024 in Portable 1 (P1) at 3:20 PM. Director states that there were 17 school age children with two teachers in Portable 1 (P1) at the time of the incident. Director states that one school age child (C1) grabbed another school age child (C2) by the left arm, swang him around, and the other child dropped to the ground. Director states that the incident was not observed by staff. Director states that C2 sustained a carpet burn on his left elbow as a result of the incident. Director states that C2 did not cry or show any discomfort as a result of the incident. Director states that a teacher tended to the child after the incident and put a band aid on the child's left arm.

Director states that one teacher notified the parents of C2 of the incident at pick up time. Director states that the child complained of discomfort on the evening of May 13, 2024 and the child was taken to El Camino Hospital for observation. Director states that X-rays were inconclusive since the child had swelling in the left elbow. Director states that C2 has the left arm wrapped in a padded cotton elastic bandage to minimize movement of the left elbow. Director states that C2 is still enrolled at the Facility and has no restrictions at this time.

Based on the available evidence, it is concluded that a child sustained an injury on May 13, 2024 and the incident was not observed by staff.

This presents a potential health & safety risk and thus a "Type B" deficiency is cited on the attached page (809-D). Exit interview conducted and report was reviewed with the Director, Emerson Ventura, and copy of appeal rights was provided. A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/23/2024 03:33 PM - It Cannot Be Edited


Created By: Melvin S Matos On 05/23/2024 at 02:48 PM
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: CALIFORNIA YOUNG WORLD AT SAN MIGUEL
FACILITY NUMBER: 434400032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision: 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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Emerson Ventura, Director, agreed to submit a written Plan of Correction to LPA Matos by Friday May 31, 2024 indicating additional procedure(s) that have been/will be implemented to ensure that children are supervised at all times.
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This requirement was not met as evidenced by: one school age child sustained an injury to the child's left elbow in Portable 1 (P1) on 05/13/24. The incident was not observed by staff. This presents a potential risk to the health, safety or 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:Belinda Devall
LICENSING EVALUATOR NAME:Melvin S Matos
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024


LIC809 (FAS) - (06/04)
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