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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703885
Report Date: 05/09/2022
Date Signed: 05/09/2022 01:10:56 PM


Document Has Been Signed on 05/09/2022 01:10 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:CALIFORNIA YOUNG WORLD # 5FACILITY NUMBER:
430703885
ADMINISTRATOR:ANGEL TORNOFACILITY TYPE:
850
ADDRESS:1110 FAIRWOOD DRIVETELEPHONE:
(408) 245-7285
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:104CENSUS: 42DATE:
05/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Angel TornoTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mel Matos met with Angel Torno, director, for an unannounced case management inspection. Purpose of today's inspection: Investigate an Unusual Incident that the Facility self reported to the Department on April 27, 2022.

Director states that the Unusual Incident occurred on April 26, 2022 at approximately 4:30 PM. Director states that Room 5 was outside in the preschool playground area (12 children & 2 teachers). Director states that one preschool child proceeded to run to the entry/exit gate to meet the child's father when the father arrived to pick up the child. Director states that the child's father came into the main office (located next to the front gate) and advised Director that the child had come to greet him at the front gate. Director states that she immediately went outside to the preschool playground and discussed the incident with staff.

Director states that staff were not aware that the preschool child had ran to the entry/exit gate to meet the child's father. Director states that the child did not exit the entry/exit gate and was on the Facility premises at all times.

LPA toured the preschool playground area with Director during today's investigation and observed that the preschool playground is adequately fenced and secure. However, it is noted that Facility staff must be stationed in the vicinity of the area leading to the entry/exit gate to ensure that the preschool children are supervised at all times.

It is concluded that a preschool child was not being adequately supervised in the outdoor preschool playground and the child was able to run to the entry/exit gate to meet the child's father on April 26, 2022. A Type B deficiency is cited on the attached page (LIC 809-D).
Exit interview conducted, appeal rights provided, and report was reviewed with Angel Torno, director. Notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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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Document Has Been Signed on 05/09/2022 01:10 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: CALIFORNIA YOUNG WORLD # 5
FACILITY NUMBER: 430703885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2022
Section Cited

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Responsibility for providing care and supervision: The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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This requirement was not met as evidenced by: one preschool child proceeded to run to the entry/exit gate from the outdoor preschool playground to meet the child's father when the father arrived to pick up the child on April 26, 2022.
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Director agreed to submit copies of training materials/meeting agenda to LPA Matos by Thursday May 12, 2022. LPA reminded Director that an office meeting at the San Jose Child Care District Office will also be scheduled at a later date.

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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) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
LIC809 (FAS) - (06/04)
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