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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 354416103
Report Date: 09/19/2019
Date Signed: 10/17/2019 10:11:16 AM



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
09/13/2019 and conducted by Evaluator Joseph Macias
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20190913165413
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:
09/19/2019
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Christina BarrientosTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff failed to pick day-care child up from school.
INVESTIGATION FINDINGS:
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This is an amended report.
Licensing Program Analysts (LPAs) Joe Macias, and Susy Cervantes conducted an unannounced inspection in order to initiate the 10-day complaint investigation of above allegation. LPAs met with the Site Supervisors Christina Barrientos to discuss complaint allegation.

LPAs Macias and Cervantes interviewed the Site Supervisor, staff, and Complainant, as well as obtained copies of pertinent information. Allegation states (staff failed to pick day-care child up from school). Based on the information gathered; the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. 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. A finding that is substantiated means the preponderance of evidence was found.

Type A deficiency cited, civil penalty assessed, exit interview conducted and copy of this report 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.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 07-CC-20190913165413
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: HOLLISTER CHILD DEVELOPMENT CENTER, LLC
FACILITY NUMBER: 354416103
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2019
Section Cited
CCR
101229(a)(1)
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Responsibility for Providing Care and Supervision:
No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Director shall conduct a training on supervision, as well as update the pick up procedure and policy. Director shall submit proof of training, and updated policy to CCL by the POC date.
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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. This poses an immediate risk to the health, safety, and personal rights of children in care.
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AB633 to issued to all parents of children in care, signed, filed in each child's file, and provider to do the same for all new clients for the next 12 months to this day.
*$500. civil penalty assessed.
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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: 09/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 07-CC-20190913165413
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: HOLLISTER CHILD DEVELOPMENT CENTER, LLC
FACILITY NUMBER: 354416103
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2019
Section Cited
CCR
101212(d)(1)(C
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Amended report, no type B issued.
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Amended report.
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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
LIC9099 (FAS) - (06/04)
Page: 3 of 3