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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415141
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:52:50 PM


Document Has Been Signed on 11/30/2023 12:52 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:SANTA LUCIA MIGRANT SEASONAL HEAD STARTFACILITY NUMBER:
274415141
ADMINISTRATOR:WILLIAM CASTELLANOSFACILITY TYPE:
850
ADDRESS:618 WALNUT AVENUETELEPHONE:
(831) 674-5725
CITY:GREENFIELDSTATE: CAZIP CODE:
93927
CAPACITY:72CENSUS: 4DATE:
11/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Norma MeloTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Deanna Villagrana met with Director, Norma Melo for a case management inspection to follow-up on an unusual incident report (UIR) the preschool self reported and received by Licensing on 11/08/2023. LPA observed four children, two teachers and one aide in Toddler Class A room 2.

It was reported by teacher 1 that she observed child 1 using a vape device called Flum Pebble on the children's playground. Child stated he brought it from child's cousin's house. Director stated the facility playground is checked every morning to ensure it is safe for the children. The playground is located in between two buildings and is fenced off to the public. LPA observed the playground is very clean for children. The child was located in the sandbox that is not near the fence which also has a tarp that covers the sandbox and fencing. The playground can be accessed if someone from the public jumps over the fence. Director stated after the incident, the facility is requesting camera's be placed to ensure no such thing will happen. There were seven children and two teachers present when the incident occurred. Children were supervised during incident. LPA obtained photos of the facility playground and of the the vape devise which is clean and does not look like it could have been located in the sandbox. The child returned to the facility and was present during today's visit.

No Deficiency was cited.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Susy CervantesTELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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