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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700555
Report Date: 01/11/2024
Date Signed: 01/11/2024 10:11:50 AM


Document Has Been Signed on 01/11/2024 10:11 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:SANTA CLARA PARENTS NURSERY SCHOOLFACILITY NUMBER:
430700555
ADMINISTRATOR:SARA QUASTFACILITY TYPE:
850
ADDRESS:471 MONROE STREETTELEPHONE:
(408) 248-5131
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:24CENSUS: 14DATE:
01/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sara QuastTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Mel Matos met with Sara Quast, director, for an unannounced case management investigation. Purpose of today's investigation: discuss an Unusual Injury that the Facility self reported to the Department on December 11, 2023.

The Unusual Injury occurred on Friday December 8, 2023 in the playground area of the Facility. Sara states that one preschool child was standing on the platform in front of the spiral pole of the play structure. Sara states that the child went to grab the spiral pole and fell onto the tanbark area of the playground.

Sara states that there was a teacher and one parent volunteer supervising the children in the playground at the time of the incident. Sara states that the teacher brought the child inside the Facility to check for injury. Sara states that the child's parents were notified via telephone and the child was picked up from the Facility. Sara states that the child was taken to Kaiser - Santa Clara and diagnosed with a hairline fracture of the child's right upper arm. Sara states that no further medical treatment was required. Sara states that the child returned to the Facility the next day and is doing fine.

LPA toured the playground and observed the play structure where the incident occurred. The play structure is age appropriate (2-5 years) and the height of the play structure to the ground (wood chips) is four feet. LPA observed sufficient wood chips (5 inches depth) in the area surrounding the play structure where the incident occurred.

Based on the available information and observations during today's investigation, it is concluded that the play structure is age appropriate with sufficient resilient materials. No deficiencies issued as a result of the incident.

Exit interview conducted and report was reviewed with the Director, Sara Quast.

Notice of site visit issued and must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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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