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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700549
Report Date: 11/21/2022
Date Signed: 11/22/2022 08:45:57 AM


Document Has Been Signed on 11/22/2022 08:45 AM - 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: 25DATE:
11/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Angela GomezTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Anna Morales conducted a Case Management Visit and was greeted by Executive Director Angela Gomez. The Purpose of the Case management visit is to address the discrepancy discovered during a complaint investigation.

The investigation revealed that the medication for Child (C1)was administered based on parent/authorized instruction which conflicts with the with prescription order on record

As a result of this investigation, a Type B deficiency was cited on the following page, LIC809 D.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.

Exit Interview was conducted with the Executive Director and APPEALS RIGHT were given.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/22/2022 08:45 AM - 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: 11/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2022
Section Cited

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101226(3)(A):Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician.
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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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2