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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706092
Report Date: 10/29/2024
Date Signed: 10/29/2024 11:03:55 AM

Document Has Been Signed on 10/29/2024 11:03 AM - 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:CHANDLER TRIPP HEAD STARTFACILITY NUMBER:
430706092
ADMINISTRATOR/
DIRECTOR:		TAFOYA, VICKIFACILITY TYPE:
850
ADDRESS:780 THORNTON WAYTELEPHONE:
(408) 573-4894
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 40TOTAL ENROLLED CHILDREN: 28CENSUS: 21DATE:
10/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Roopali BornTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico conducted a Case Management inspection regarding an incident that was reported by the facility to Licensing. LPA met with Site Director, Roopali Born. LPA toured the facility, reviewed a child's file, and interviewed staff.

Based on available information, LPA learned that on October 23, 2024 during lunch time, a child requiring milk substitutions consumed milk that was on the table. This happened when the staff member (S1) who was on the table with the children got up to redirect another child who was climbing on furniture. C1 had an allergic reaction to the milk. Staff administered medication and the parent was contacted immediately.

As a result of this inspection, Type B deficiency was cited on the following page.

Exit interview conducted and report was reviewed with Site Director, Roopali Born.

A Notice of Site Visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 10/29/2024 11:03 AM - It Cannot Be Edited


Created By: Marilou Monico On 10/29/2024 at 10:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CHANDLER TRIPP HEAD START
FACILITY NUMBER: 430706092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2024
Section Cited
CCR
101229(a)(2)

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Personal Rights - (a) The licensee shall ensure that each child is accorded the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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 By POC due date: 11/01/24, Roopali stated that she will submit a written plan detailing the steps she already completed with staff and what needs to be done to prevent this incident from occurring again.
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This requirement was not met as evidenced by: On 10/23/24, a child (C1) requiring milk substitutions consumed milk that was on the table when the staff (S1) got up to redirect another child who was climbing on furniture. This poses a potential risk to the health, safety, and personal rights to children 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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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