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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408808
Report Date: 05/23/2023
Date Signed: 05/23/2023 01:39:48 PM

Document Has Been Signed on 05/23/2023 01:39 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:LOS GATOS CHRISTIAN SCHOOL & PRESCHOOLFACILITY NUMBER:
434408808
ADMINISTRATOR:RAMIREZ, WENDYFACILITY TYPE:
850
ADDRESS:16845 HICKS ROADTELEPHONE:
(408) 997-4681
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY: 100TOTAL ENROLLED CHILDREN: 47CENSUS: 39DATE:
05/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Wendy RamirezTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Kassandra Medrano, conducted an unannounced Case Management Inspection in response to an unusual incident that the facility self reported to Community Care Licensing (CCL) on 5/17/2023. LPA met with the Director, Wendy Ramirez, and explained the nature of today's inspection.
This visit was made to inquire about an unusual incident that occurred on May 15, 2023.

During today's visit LPA Medrano toured the facility, interviewed staff, and reviewed pertinent documents. It was reported to facility by a guardian that their child sustained an unexplained bruise in care and child reported that staff mishandled them while in care. Based on staff interviews, review of video footage, as well as the self reported incident report. It was found that staff not only mishandled one child but another as well. LPA observed staff grab the children by their arm and pull them down from the structure.

Exit interview conducted, and a copy of this report was provided and reviewed with the Director, Wendy.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):



"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS. LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH APPLICANT/PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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 05/23/2023 01:39 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 05/23/2023 at 11:04 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: LOS GATOS CHRISTIAN SCHOOL & PRESCHOOL
FACILITY NUMBER: 434408808

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2023
Section Cited
CCR
101223(c)

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101223 Personal Rights
(c) The licensee shall ensure that each child is accorded the personal rights specified in this section.
The requirement was not as evidenced by:
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Director to conduct a staff training for all staff and to provide documentation on what was convered as well as sign in sheet for those in attendance.
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During interviews, and review of video footage it was found that a teacher mishandled children while in care. Which poses a immediate risk to 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:Diana Stephenson
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023


LIC809 (FAS) - (06/04)
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