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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416103
Report Date: 08/21/2019
Date Signed: 08/21/2019 09:50:59 AM

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:HOLLISTER CHILD DEVELOPMENT CENTER, LLCFACILITY NUMBER:
354416103
ADMINISTRATOR:ALMA MAY BAYANI, PSYDFACILITY TYPE:
840
ADDRESS:331 GATEWAY DRIVETELEPHONE:
(831) 625-9284
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:56CENSUS: 0DATE:
08/21/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Christina BarrientosTIME COMPLETED:
09:50 AM
NARRATIVE
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Licensing Program Analyst (LPA), Joseph 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 Christina Barrientos, site supervisor, and explained the nature of today's visit to her. The school age hours of operation are Monday - Friday, 2pm - 6pm.

This visit was made to inquire about an unusual incident that occurred on July 22, 2019.

During today's visit LPA Macias interviewed staff, reviewed facility files, and obtained copies of pertinent information. Based on staff interviews, as well as the self reported incident report; a child may have violated another child's personal rights. The incident did not occur at the facility, and both children involved have aged out of the program. The alleged incident happened online while the two children involved were playing a video game.

As a result of the incident the Site Supervisor has reviewed children's personal rights with all staff.


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: 08/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019
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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