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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709874
Report Date: 09/13/2024
Date Signed: 09/13/2024 10:28:43 AM


Document Has Been Signed on 09/13/2024 10:28 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
SAN JOSE CC RO, 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: 0DATE:
09/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Angel TornoTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Mel Matos met with Angel Torno, Director, for an unannounced case management inspection in response to an Unusual Incident that the Facility reported to the Department on Friday September 6, 2024.

Director states that Unusual Incident occurred on Thursday September 5, 2024 at 3 PM. Director states that there were 20 school age children and two teachers from Room 8 outdoors in the playground area at the time of the incident. Director states that a school age child left the school age playground via an entry/exit gate that was inadvertently left unlocked by the elementary school. Director states that the entry/exit gate is normally locked during school hours. Note: the Facility is located on the campus of Fairwood Elementary School. Director states that the staff observed the child leaving and immediately notified her and other staff to come provide coverage for Room 8.

Director states that the child ended up walking home, located approximately one block from campus. Director states that the two teachers followed the child and states that the child was never "out of sight" of the teachers. Director states that the child's nanny, who is listed as an authorized person on the LIC 700 form was present at the home. Director states that the staff talked to the child's nanny and explained the incident. Director states that the child told staff that he "wanted to go home" and thus the reason he left the school age playground.

Director states that she called the child's father after the incident to advise him of the incident. Director states that the child was brought back to the Facility by the two staff and the child stayed at the Facility until he was eventually picked up by his father at 4:15 PM. Director states that she talked to the child and father about the incident and reminded them that children are not allowed to leave the Facility unless they are signed out by an authorized representative.

Director states that the child returned to the Facility and is still enrolled. Director states that the child had not attempted to leave the Facility prior to this incident. Director states that she has talked to staff about ensuring that the entry/exit gate is locked at all times. Director states that she has also talked to the staff from Fairwood Elementary School about keeping the entry/exit gate locked at all times during school hours.

Based on the available evidence, it is concluded that a child did left the school age playground via an entry/exit gate on September 5, 2024; however, Facility staff followed the child and the child was never "out of sight" of the staff.

Exit interview conducted and report was reviewed with the Director, Angel Torno. A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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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