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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430703695
Report Date: 06/08/2021
Date Signed: 06/08/2021 11:46:08 AM



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
03/30/2021 and conducted by Evaluator Janette Cruz
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20210330155333
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: 81DATE:
06/08/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ann-Marie LemmermanTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility has mold in walls.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs)Janette Cruz and Mel Matos conducted an unannounced complaint inspection investigation and met with Ann-Marie Lemmerman, Director. Purpose of today’s inspection: deliver investigation findings.

In regard to above allegation of “facility has mold in walls”, LPAs toured toddler classroom 2A and interviewed two staff for this complaint investigation. LPAs observed mold growth on the back wall and ceiling on top of cabinet near bathroom where binders were kept. LPAs observed mold and moisture build-up inside and under the cabinet.
Based on LPAs observations, record reviews and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 12 & Chapter 1), is being cited on the attached LIC 9099-D. Copy of appeal rights provided to Ann-Marie Lemmerman prior to conclusion of today’s inspection.
A Notice of Site Visit is issued and must be posted near the entrance to the facility for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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 3
Control Number 07-CC-20210330155333
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 430703695
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2021
Section Cited
CCR
101238(a)
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101238 (a) Buildings and Grounds. The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.This requirement is not met as evidenced by:
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Licensee submitted proof of inspection report and repairs done on the walls and ceiling to remove mold growth on 5/13/21.

Deficiency is cleared.
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Based on observations, record reviews and interviews conducted, Licensee did not ensure clean, safe and sanitary condition of the facility at all times. LPAs observed mold growth on the back wall and ceiling on top of cabinet located in toddler classroom 2A. LPAs observed moisture and mold growth inside and under the cabinet which pose potential Health and Safety risk to persons in care.

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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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
03/30/2021 and conducted by Evaluator Janette Cruz
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20210330155333

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: 81DATE:
06/08/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ann-Marie LemmermanTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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2
3
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5
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9
Comingling use of bathrooms.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs)Janette Cruz and Mel Matos conducted an unannounced complaint inspection investigation and met with Ann-Marie Lemmerman, Director. Purpose of today’s inspection: deliver investigation findings. In

In regard to above allegation of “comingling use of bathrooms”, LPAs interviewed four staff for this complaint investigation and conclude that the facility has separate bathrooms for toddlers and pre-school children to follow current cohort guidelines.
Based on observations, record reviews and interviews completed for the complaint investigation, it is concluded that although the allegations noted on this complaint may have happened or valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. The allegations are thus UNSUBSTANTIATED.

A Notice of Site Visit is issued and is required to be posted near the entrance to the facility for 30 days.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3