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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710093
Report Date: 04/27/2022
Date Signed: 04/27/2022 01:25:53 PM


Document Has Been Signed on 04/27/2022 01:25 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:LYNDALE HEAD STARTFACILITY NUMBER:
430710093
ADMINISTRATOR:SOUSA, PEDROFACILITY TYPE:
850
ADDRESS:13901 NORDYKE DRIVETELEPHONE:
(408) 258-1523
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:48CENSUS: 15DATE:
04/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Martha MoralesTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Anna Morales conducted a Case Management Visit and was greeted by Site Director Martha Morales. The purpose for this visit was in response of an Incident that occurred on 4/8/2022. Site Director Martha Morales stated that a Preschool aged child was left outside in the play ground without supervision from staff.

LPA conducted interviews with Site Director Morales, and teachers involved with the incident. LPA, also, toured the Classroom and the playground. The playground is enclosed with a secured fence. There are two classrooms and Lyndale Classroom One is the only classroom being used at this time. Site Director stated that the day of the incident there were a total of 15 children and three teachers present. On 4/8/22, approximately at 11:30am, the children and two staff lined up the children to come back inside the classroom to eat lunch. S1 was at the front of the line and a Special Educator was at the end of the line with two of the children from the Inclusion Program. When the children enter the classroom they go wash their hands prior to eating. S2 was already in the classroom's bathroom assisting a child, and stayed to supervise the other children who came to wash their hands. S1 had left the classroom with a child who was not feeling well to the isolation area and stayed to supervise. S3 was preparing snacks and came into the classroom at 11:15am and waited for the children and staff to come inside to eat. S3 stated that she had scanned the classroom and heard a "whimpering/crying noise" coming from the back door( leading to the playground) and observed C1 sitting on the steps without staff supervision. According to the conducted interviews, C1 was left outside for approximately 45- 50 seconds, and a head count was not conducted prior to returning to the classroom to eat their lunches.

California Code of Regulations, (Title 22, Division 12 & Chapter 1), is being cited on the attached LIC 809D. A notice of site visit was issued and is to be posted near the facility entrance along with the Type "A" deficiency issued today and both notices must remain posted for 30 consecutive days. The Licensee must provide copies of this report to parents/guardians of children in care at this facility and Acknowledgement of Receipt of Licensing Reports (LIC9224) to parents/guardians of children newly enrolled at this facility during the next 12 months, and parents to return this form with signature to the facility.

Exit Interview was conducted with Director Martha Morales. Appeal Rights given.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
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 04/27/2022 01:25 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: LYNDALE HEAD START
FACILITY NUMBER: 430710093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2022
Section Cited

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Responsibility for Providing Care and Supervision - (a)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: A child was found by a staff member unattended on the doorsteps of (LYNDALE CLASSROOM ONE) that leads to the outside playground whimpering/crying on April 8, 2022. This poses an immediate risk to the health, safety, and personal rights to children in care.
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According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months & copy of the signed acknowledgment form must be kept in each child's file.

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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: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
LIC809 (FAS) - (06/04)
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