430703695-5-13-2020-07-CC-DSTN-BPLT33-20200514142138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430703695
Report Date: 05/13/2020
Date Signed: 05/13/2020 04:57:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/18/2020 and conducted by Evaluator Dung Mac

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20200218095303

FACILITY NAME:	SJB - SAN JUAN BAUTISTA CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	430703695
ADMINISTRATOR:	NIKITTIN, YULIANA		FACILITY TYPE:	850
ADDRESS:	1945 TERILYN AVENUE		TELEPHONE:	(408) 259-4796
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	231	CENSUS: 0	DATE:	05/13/2020
		UNANNOUNCED	TIME BEGAN:	04:41 PM
MET WITH:	Melissa Leza		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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- Child sustained injury while in care.

- Staff failed to adhere to the parent hand book policy.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dung Mac conducted a Tele-Investigation via video conference call with Program Director, Melissa Leza. The findings for the above allegations were delivered to the facility during this Tele-Investigation. Facility was informed that due to COVID-19 situation and "Shelter In Place" Order, this LIC 9099 Complaint Investigation Report will be emailed to the Facility with "Read Receipt" notification in lieu of a physical visit to the facility.

During the course of the investigation, staff were interviewed and staff files were reviewed. Based on the interviews and records reviewed obtained through investigation, LPA concluded that although the allegations noted on this complaint: 1) Child sustained injury while in care and 2) Staff failed to adhere to the parent hand book policy, may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. The allegations are therefore UNSUBSTANTIATED.

Exit interview was conducted, where this report was reviewed with Program Director over tele-investigation. A Notice of Site Visit will be sent to Facility via email and must remain posted for 30 days.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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