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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703695
Report Date: 05/08/2019
Date Signed: 05/08/2019 04:32:13 PM

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:SJB - SAN JUAN BAUTISTA CHILD DEVELOPMENT CENTERFACILITY NUMBER:
430703695
ADMINISTRATOR:NIKITTIN, YULIANAFACILITY TYPE:
850
ADDRESS:1945 TERILYN AVENUETELEPHONE:
(408) 259-4796
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:231CENSUS: 86DATE:
05/08/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Yuliana NikittinTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Shannel Reed conducted an unannounced, Case Management inspection to the facility today. LPA met with Regional Director, Yuliana Nikittn, and informed her of the purpose of today’s visit was to investigate an Unusual Incident regarding a child being bitten while in care. LPA spoke with the Regional Director and the primary Teacher, Mayra Harms, who was mentioned in the Unusual Incident Report as the supervising teacher, regarding the incident. LPA obtained the facility roster and the children’s contact information. The Site Supervisor, Lindsay Masuda, was not present during todays inspection. She will email her and Mayra’s notes from their interviews with the children and the parents to LPA by tomorrow, 05/09/19.

No Title 22 deficiencies were cited during today's inspection.

A NOTICE OF SITE VISIT WAS ISSUE AND MUST BE POSTED IN THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Shannel ReedTELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
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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