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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700549
Report Date: 11/17/2023
Date Signed: 11/22/2023 11:45:11 AM

Document Has Been Signed on 11/22/2023 11:45 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 CC RO, 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: 88TOTAL ENROLLED CHILDREN: 88CENSUS: 43DATE:
11/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angela GomezTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Morales conducted a Case Management inspection to follow up on an Unusual Incident that was reported by the facility to Licensing on 11/15/23. LPA was greeted by Executive Director Angela Gomez. LPA toured the facility, interviewed staff, and reviewed files.

Based on interviews and evidence gathered, it was determined that on 11/15/23, approximately at 10:20am, a Preschool aged child was left unattended for approximately five to seven minutes in the bathroom located in the playground during free play. This poses an immediate risk to the health, safety, and personal rights to children in care.

A Type A citation was issued at today's visit, and a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for the next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files. The citation warrants an immediate civil penalty of $500.00 and is hereby assessed, See LIC421IM. An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Director. Appeal Rights Given.


A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Anna Morales
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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 11/22/2023 11:45 AM - It Cannot Be Edited


Created By: Anna Morales On 11/17/2023 at 10:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2023
Section Cited

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Responsibility for Providing Care and Supervision(a)(1) 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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This requirement was not met as evidenced by: A child was left unattended in the bathroom located in the outside playground on November 15,2023.This is a zero tolerance violation. This poses an immediate risk to the health, safety, and personal rights to children in care.
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 inspection.Upon receipt, Director shall post and provide copies of this licensing report, have LIC 9224 signed and kept on file, to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months & copy of the signed acknowledgment form must be kept in each child's file.

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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 Kuizon
LICENSING EVALUATOR NAME:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
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