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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412414
Report Date: 05/08/2024
Date Signed: 05/08/2024 03:28:54 PM

Document Has Been Signed on 05/08/2024 03:28 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:CATALYST KIDS - SEDGWICKFACILITY NUMBER:
434412414
ADMINISTRATOR/
DIRECTOR:		PONAYUR, USHAFACILITY TYPE:
850
ADDRESS:19200 PHIL LANETELEPHONE:
(408) 725-0909
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 44TOTAL ENROLLED CHILDREN: 16CENSUS: 12DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:11 PM
MET WITH: Laura Beck & Alyssa ScholesTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico met with Program Lead, Laura Beck, and Regional Director, Alyssa Scholes, for a Case Management inspection in response to an unusual incident that was self-reported by the facility to Licensing on 05/07/24 involving two preschool children (C1 & C2). During today's visit, LPA toured the facility, reviewed records and interviewed staff.

Based on the information gathered during the investigation process, on May 6, 2024, two preschool age children (C1 & C2) were left unsupervised in front of Room 33 when the teacher (S1) went inside the classroom to get a water bottle.

As a result of this inspection, Type A deficiency was issued.

LPA informed Program Lead that this report dated 05/08/24 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Assembly Bill 633 was provided and discussed with Program Lead. LPA informed the Program Lead to provide a copy of this licensing report dated 05/08/24 that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to parents/guardian of newly enrolled children for the next 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with Program Lead, Laura Beck.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS ALONG WITH TYPE A CITATION.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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 05/08/2024 03:28 PM - It Cannot Be Edited


Created By: Marilou Monico On 05/08/2024 at 02:11 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: CATALYST KIDS - SEDGWICK
FACILITY NUMBER: 434412414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care & 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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By POC due date: 05/09/24, Program Lead & Regional Director stated that a written plan to ensure that the children are supervised at all times will be submitted to Licensing.
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This requirement was not met as evidenced by: Two children were left unsupervised in front of Room 33 when the teacher went inside the classroom to get a water bottle. This posed an immediate risk to the health, safety, or personal rights to children in care.
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Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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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: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024


LIC809 (FAS) - (06/04)
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