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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274400409
Report Date: 07/11/2019
Date Signed: 07/11/2019 04:05:04 PM

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:PRIMAVERA MIGRANT HEAD STARTFACILITY NUMBER:
274400409
ADMINISTRATOR:WILLIAM CASTELLANOSFACILITY TYPE:
850
ADDRESS:24228 LINCOLN STREETTELEPHONE:
(831) 679-0503
CITY:CHUALARSTATE: CAZIP CODE:
93925
CAPACITY:45CENSUS: DATE:
07/11/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ethel WilkinsonTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Joe Macias, conducted an unannounced case management visit in response to an unusual incident that the facility self reported to Community Care Licensing (CCL). LPA met with Ethel Wilkinson, Site Supervisor, and explained the nature of today's visit.

This visit was made to inquire about an unusual incident that occurred on May 30, 2019.

During today's visit LPA Macias interviewed the Site Supervisor, reviewed facility files, and obtained copies of pertinent information. Based on staff interviews, as well as the self reported incident report; a child's personal rights may have been violated. The facility responded appropriately by reporting to CCL, and providing an all staff training on children's personal rights. The Site Supervisor is checking in with all staff and ensuring Children are treated with dignity and respect.

No deficiencies cited, exit interview conducted, and a copy of this report was provided to the facility.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Joseph MaciasTELEPHONE: (408) 334-8320
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2019
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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