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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700549
Report Date: 08/18/2022
Date Signed: 08/18/2022 02:00:22 PM


Document Has Been Signed on 08/18/2022 02:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:SAN JOSE DAY NURSERYFACILITY NUMBER:
430700549
ADMINISTRATOR:ELENA JOLLYFACILITY TYPE:
850
ADDRESS:33 NORTH 8TH STREETTELEPHONE:
(408) 288-9667
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:88CENSUS: 47DATE:
08/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Angela GomezTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Kaur, conducted an unannounced Case Management/ Incident Inspection in response to an unusual incident that the facility self reported to Community Care Licensing (CCL). LPA met with the Assistant Director, and explained the nature of today's visit.

This inspection was made to inquire about unusual incidents that occurred on August 12 2022.

During today's visit LPA Kaur toured the facility, interviewed staff, and obtained copies of pertinent documentation. Based on interviews, as well as the self reported incident report; a child's personal rights were violated.

Since the incidents occurrence San Jose Day Nursery school has been proactive in self reporting to CCL as well as CPS. Nursery school has immediately implemented several interventions: staff training's, professional development, and disciplinary actions. LPA Kaur reviewed with the Director that each child is accorded the following personal rights: to be accorded dignity in his/her personal relationships with staff and other persons. 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.

As a result of this Inspection, 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 CONSEC

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Harsimran KaurTELEPHONE: (408) 529-3696
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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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Document Has Been Signed on 08/18/2022 02:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: SAN JOSE DAY NURSERY
FACILITY NUMBER: 430700549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2022
Section Cited

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Personal Rights. The licensee shall ensure that each child is accorded the following personal rights: 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.
This requirement was not met as evident by:
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Based on information obtained, S-1 hit on C-1's wrist. C-1 did not obtain any injuries a a result of this incident. This poses a potential risk to the health and safety to the child 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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Harsimran KaurTELEPHONE: (408) 529-3696
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
LIC809 (FAS) - (06/04)
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