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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414001188
Report Date: 08/12/2021
Date Signed: 08/12/2021 04:51:51 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2021 and conducted by Evaluator April Cowan
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20210811161629
FACILITY NAME:BORDESSA, JODY D.FACILITY NUMBER:
414001188
ADMINISTRATOR:BORDESSA, JODY D.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 359-2683
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY:14CENSUS: 23DATE:
08/12/2021
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Jody BordessaTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Facility operates over capacity
INVESTIGATION FINDINGS:
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On August 12, 2021 at 1:50 PM, Licensing Program Analyst (LPA) Cowan conducted an initial complaint inspection. LPA met with licnsee, and the purpose of the inspection was explained. LPA was granted entry by licensee
During today's inspection, LPA toured facility. At 1:55 PM, LPA observed 23 children, and four of which are under 12 months. LPA obtained Child Care Facility Roster.

Based on LPA’s observation, the preponderance of evidence standard has been met, therefore the above allegation(s) is founded to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.
This report and appeals right will be emailed to licensee with a request for reply demonstrating receipt
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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 2
Control Number 05-CC-20210811161629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BORDESSA, JODY D.
FACILITY NUMBER: 414001188
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2021
Section Cited
CCR
102416.5(a)
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102416.5 Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement was not met as evidenced by:
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Licensee agree to have parents come and pick up children immediately.
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During todays inspection, LPA observed 23 children in care. This poses an immediate 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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2