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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416103
Report Date: 10/17/2019
Date Signed: 10/17/2019 10:15:42 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:
10/17/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Christina BarrientosTIME COMPLETED:
10:20 AM
NARRATIVE
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Licensing Program Analyst (LPA), Joseph Macias, conducted an unannounced Case Management Inspection. LPA met with Christina Barrientos, site supervisor, and explained the nature of today's visit to her.

This visit was made to inquire about an incident that occurred on September 13, 2019.

The facility failed to pick up a child from school who is enrolled in the school age program. The child was left at the school. The Director states the parent was not notified. The facility failed to report the incident to CCL. LPA Macias explained that any unusual incident or child absence that threatens the physical or emotional health or safety of any child must be reported to the Department by telephone or fax within the Department's next working day.

As a result of this visit, a deficiency was cited.

Appeal right were printed and reviewed with the staff.

Type B deficiency 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: 10/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: HOLLISTER CHILD DEVELOPMENT CENTER, LLC
FACILITY NUMBER: 354416103
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2019
Section Cited

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Reporting Requirements:
Any unusual incident or child absence that threatens the physical or emotional health or safety of any child shall be reported to the Department by telephone or fax within the Department's next working day.
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The child was left at the school, the Director states the parent was not notified. The facility failed to report the incident to CCL.
This poses a potential risk to the health, safety, and personal rights of 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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Joseph MaciasTELEPHONE: (408) 334-8320
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2019
LIC809 (FAS) - (06/04)
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