430703695-3-13-2024-07-CC-SYIP-D3BW4M-20240313165745

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430703695
Report Date: 03/13/2024
Date Signed: 03/13/2024 04:57:52 PM

Document Has Been Signed on 03/13/2024 04:57 PM - 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:	SJB - SAN JUAN BAUTISTA CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	430703695
ADMINISTRATOR:	ANN-MARIE LEMMERMAN		FACILITY TYPE:	850
ADDRESS:	1945 TERILYN AVENUE		TELEPHONE:	(408) 259-4796
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	176	CENSUS: 76	DATE:	03/13/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Lurvin Magana-Calles and Maria Velazquez		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management-Incident inspection. LPA met with Site Director Lurvin Magana-Calles and explained the reason for the inspection. Associate Program Director Maria Velazquez arrived shortly after. The purpose of this inspection is to review a self-reported incident that occurred on 02/28/2024 regarding absence of supervision. Incident was self-reported to the San Jose Regional office on 03/06/2024. During today's inspection, LPA interviewed staff and inspected the physical plant. LPA also obtained staff matrix from the day of the incident, which has the number of children. Based on interviews, a child was left in the Pre- 7 room without the supervision of a teacher on 02/28/2024. The room was transitioning from inside to the outside area. Staff conducted a head to face count when they arrived to the outside area, then went back to the classroom where the child was. Director and Associate Program Director stated that they will be conducting training with the individual staff involved in the incident. The center will also be conducting training all their staff regarding supervision and transitions on 03/21/2024. ----------------CONTINUES ON 809 DATED 03/13/2024 PAGE 2------------------

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
	VISIT DATE: 03/13/2024

NARRATIVE

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----------------CONTINUATION OF 809 DATED 03/13/2024 PAGE 1-----------

As a result of this inspection, a Type A citation was issued. A civil penalty of $500 was assessed for Immediate $500. Exit interview conducted and report was reviewed with Site Director Lurvin Magana-Calles and Associate Program Director Maria Velazquez. A notice of site visit has been issued and must remain posted for 30 days.

LPA Samantha Yip informed Site Director Lurvin Magana-Calles and Associate Program Director Maria Velazquez that this report dated 03/13/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Director, Lurvin, and Associate Program Director, Maria, to provide a copy of this licensing report dated 03/13/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/13/2024 04:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/13/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/14/2024 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	By POC 03/14/2024, the center will submit written plan outline when training will be conducted with staff regarding supervision and how they
	8 9 10 11 12 13 14	Based on interviews, a child was left in the Pre 7 room without any teacher supervising at the time, which poses an immediate health and safety risk to children in care.	8 9 10 11 12 13 14	will ensure children are not left without supervision of a teacher at any time. The center will submit meeting notes and list of staff who attended training to Licensing upon completion
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC809 (FAS) - (06/04)

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