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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709874
Report Date: 07/21/2022
Date Signed: 07/21/2022 10:03:42 AM


Document Has Been Signed on 07/21/2022 10:03 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:CALIFORNIA YOUNG WORLD # 5 - SCHOOL AGEFACILITY NUMBER:
430709874
ADMINISTRATOR:ANGEL TORNOFACILITY TYPE:
840
ADDRESS:1110 FAIRWOOD AVENUETELEPHONE:
(408) 245-7285
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:56CENSUS: DATE:
07/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Angel TornoTIME COMPLETED:
10:15 AM
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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: discuss an Unusual Injury that the Facility self reported to the Department.

The Unusual Injury occurred on June 30, 2022 at approximately 4:50 PM. One school age child was climbing the ladder on the play structure, located in the school age playground used by the school age children. The school age child slipped, fell off the ladder (approximately 6 ft height), and landed on the rubber foam tiles (located underneath and surrounding the play structure). The incident was observed by Bruce Conrad, school age teacher. Angel states that child landed on the child's right arm and had some scrapes on the arm area as a result of the fall.

Angel states that the child's step mother arrived shortly thereafter and took the child to Kaiser Hospital - San Jose - later that day for observation. Angel states that the child was diagnosed with a broken right arm and had the right arm set in a cast. Angel states that the child returned after the Fourth of July holiday and is doing fine.

LPA toured the school age playground with Angel during today's inspection. The play structure is secure, safe, and age appropriate (5-12 years) for the school age children. LPA also observed sufficient resilient materials (rubber foam tiles) underneath and surrounding the play structure.

No deficiencies issued during today's inspection. Exit interview conducted and report was reviewed with Angel Torno, director. A 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: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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