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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710472
Report Date: 05/01/2019
Date Signed: 05/01/2019 02:41:13 PM

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:RAINBOW MONTESSORI CHILD DEVELOPMENT CENTERFACILITY NUMBER:
430710472
ADMINISTRATOR:SPYROULA RODENBORNFACILITY TYPE:
850
ADDRESS:790 DUANE AVENUETELEPHONE:
(408) 738-3261
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:378CENSUS: DATE:
05/01/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Julie LoraTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mel Matos met with Julie Lora, infant director, for an unannounced case management investigation inspection. Purpose of today's inspection: address Unusual Injury that the Facility self reported to the San Jose Regional Office on April 10, 2019. LPA also interviewed Julie, one teacher, and one day care parent during today's inspection.

Julie states that the incident occurred on April 10, 2019 at approximately 11 AM in the H-1 room. Julie states that there were two teachers, one aide, and 27 preschool children in the classroom at the time of the incident. Julie states that the children were walking over to "circle time" when one preschool (C-1) child accidentally pushed another preschool child (C-2). Julie state that C-2 fell backwards and hit the back of C-2's head on the carpeted area of the classroom. Julie states that C-2 was unconscious for a few seconds as a result of the incident. Julie states that the head teacher in the H-1 room tended to C-2 after the initial fall and states that the child was a bit disoriented for a few seconds upon regaining consciousness. Julie states that Carolina continued tending to the child and states that staff called her to come into the classroom 1-2 minutes after the incident. Julie states that she observed C-2 conscious and sitting on the head teacher's lap upon entering the classroom. Julie states that the child did not have any visible signs of injury (bump on the back of the head), did not complaint of any pain or weakness; however, she states that the C-2 did complain of dizziness. Julie states that she had the child count numbers 1-10, count fingers, and recite ABC's and states that the child was able to respond correctly and did not exhibit any signs of loss of memory. Julie states that she then picked up C-2 and carried the child to the front office. Julie states that the child did not complain of any dizziness after she brought the child to the office and she proceeded to call the child's parents to come pick up the child from the Facility. Julie states that the child's reside nearby and states that they arrived at the Facility within a few minutes.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 05/01/2019):
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2019
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 3
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: RAINBOW MONTESSORI CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 430710472
VISIT DATE: 05/01/2019
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 05/01/2019):

Julie states that the child's parents arrived around 11:30 AM and took the child to El Camino Hospital for observation. Julie states that C-2 was not diagnosed with a concussion and was released the same day. Julie states that the child returned to the Facility the following day with no restrictions.

Based on the available information and interviews conducted during today's inspection, LPA concludes that the Facility failed to make prompt arrangements for obtaining medical treatment for preschool child (C-2) after the child fell and hit the back of C-2's head in the H-1 Room on April 10, 2019. LPA notes that the Facility did tend to the needs of the child after the incident, including calling the child's parents, and thus, there was no immediate risk to the health & safety of the child.

The following deficiency is noted on attached page (809-D):


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: RAINBOW MONTESSORI CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 430710472
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2019
Section Cited
CCR
101226(b)
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Health-related services: The licensee shall make prompt arrangements for obtaining medical treatment for any child if necessary. This requirement is not met as evidenced by:
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The Licensee agreed to submit a Plan of Correction addressing what steps the Facility is going to implement to ensure that prompt arrangements are made for obtaining medical treatment for any child if
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LPA concludes that the Facility failed to make prompt arrangements for obtaining medical treatment for preschool child (C-2) after the child fell and hit the back of C-2's head in the H-1 Room on April 10, 2019.
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necessary.

This presents a potential risk to the health & safety of children.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3