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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430702544
Report Date: 06/07/2024
Date Signed: 06/20/2024 10:21:19 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/03/2024 and conducted by Evaluator Liridon Fici
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240403120940
FACILITY NAME:WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAMFACILITY NUMBER:
430702544
ADMINISTRATOR:BOBBI URBANOFACILITY TYPE:
840
ADDRESS:1425 LINCOLN AVETELEPHONE:
(408) 287-6999
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:200CENSUS: 66DATE:
06/07/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Thalia GutierrezTIME COMPLETED:
09:35 AM
ALLEGATION(S):
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Staff did not provide adequate supervision to a day care child.
INVESTIGATION FINDINGS:
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On 6/20/2024, at 9:00 AM, Licensing Program Analyst (LPA) Liridon Fici arrived unannounced to conduct a subsequent complaint investigation visit and to deliver amended findings on the above allegation. LPA met and was greeted by Thalia Gutierrez, Director substitute (DS), and explained the purpose of the visit.

During course of the investigation visit, LPA interview two (2) staff, and obtained the following documents: Staff roster for December 2023, children’s roster for December 2023, identification and emergency information, Strike meeting /intervention plan, copies of email correspondences, and parents’ handbook.




Continue on Lic9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
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 07-CC-20240403120940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAM
FACILITY NUMBER: 430702544
VISIT DATE: 06/07/2024
NARRATIVE
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It was alleged that: Staff did not provide adequate supervision to a day care child. Staff, child, and parent interviews were conducted. Records were obtained and review. Based on the evidence gathered, staff stated that children are not allowed to leave the Extended Day Program without signing in and C1 confirmed with LPA that he is not allowed to sign himself in and out without a parent. Records show C1 being signed in and out by C1’s father.

Based on interviews, record reviews, and evidence gathered during the course of the investigation, it is concluded that although the allegations noted on this complaint may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. The allegations are UNSUBSTANTIATED.

No deficiencies cited during visit.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted with DS, and a copy of this report review and provided.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
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