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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 350710320
Report Date: 05/11/2021
Date Signed: 05/11/2021 03:00:35 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2021 and conducted by Evaluator Deanna Villagrana
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20210504153248
FACILITY NAME:GO KIDS CLUB - RO HARDINFACILITY NUMBER:
350710320
ADMINISTRATOR:MITSY NAVARROFACILITY TYPE:
840
ADDRESS:761 SOUTH STREETTELEPHONE:
(831) 636-8171
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:56CENSUS: 19DATE:
05/11/2021
UNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Mitsy NavarroTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff inappropriately disciplined day care child
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Deanna Villagrana met with Director Mitsy Navarro via Facetime due to Covid-19, to deliver findings for the above allegation. LPA explained the nature of the visit to her. LPA observed 10 children with one teacher Ms. Viridiana in Room 2 and 9 children with one teacher, Miss Linda in the outside playground.

Based on LPA's observation and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A child was given gloves and helped Director clean children's bathroom after toilet flooded. California Code of Regulations, Health and Safety Code 1596.80, are being cited on the attached LIC. 9099D.

Notice of site visit was issued and must be posted for 30 days.

This report has been emailed to Director and Director will reply to the email in lieu of a signature.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 07-CC-20210504153248
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GO KIDS CLUB - RO HARDIN
FACILITY NUMBER: 350710320
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2021
Section Cited
CCR
101223(a)(3)
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To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Director will write a letter stating she understands her actions were not incompliant with regulations and how she will handle the situation in the future. Director will email to LPA by 05/14/2021.
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This requirement was not met as evidenced by a child was given gloves and helped Director clean children's bathroom after toilet flooded. This poses a potential risk Health, Safety Personal Rights 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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
LIC9099 (FAS) - (06/04)
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