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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709504
Report Date: 04/27/2023
Date Signed: 04/27/2023 04:04:47 PM


Document Has Been Signed on 04/27/2023 04:04 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:CATALYST KIDS - LOS ALAMITOSFACILITY NUMBER:
430709504
ADMINISTRATOR:CARRIE SMITHFACILITY TYPE:
840
ADDRESS:6130 SILBERMAN DRIVETELEPHONE:
(408) 268-6331
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY:90CENSUS: 64DATE:
04/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Merisa ColonTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janette Cruz, met with Merisa Colon, school -age program Teacher for an unannounced case management inspection. During today's inspection LPA observed that the criminal record clearance for staff (S8), who is assisting in classroom SAC3, was not associated to the facility. LPA notes that S8 is a substitute teacher from Child Care Careers staffing agency. S8 stated that she had only started working with Catalyst Kids Los Alamitos location today.

A deficiency was cited with civil penalty, appeal rights also given. See (809-D). Exit interview was conducted with Merisa Colon, Teacher .

A Notice of Site Visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/27/2023 04:04 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: CATALYST KIDS - LOS ALAMITOS
FACILITY NUMBER: 430709504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2023
Section Cited

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101170 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 101170(f)
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Licensee shall associate staff, S8's criminal record clearance to the facility prior to returning to work in the facility by POC due date. Civil Penalty of $100 assessed. (See LIC421BG)
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Based on observation, interview and record review, Licensee did not comply with section cited above. Licensee did not associate staff (S8's)criminal record clearance to the facility which poses a potential health, safety or personal rights 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: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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