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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430710536
Report Date: 05/07/2020
Date Signed: 05/11/2020 09:21:11 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/20/2020 and conducted by Evaluator Janet Tse
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20200220150146
FACILITY NAME:YWCA DAVIDSONFACILITY NUMBER:
430710536
ADMINISTRATOR:RODRIGUEZ, JEANINEFACILITY TYPE:
850
ADDRESS:375 SOUTH THRID STREETTELEPHONE:
(408) 295-4011
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:67CENSUS: 7DATE:
05/07/2020
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Jeanine RodriguezTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Lack of supervision resulting in child repeatedly being injured.
INVESTIGATION FINDINGS:
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Due to the COVID-19 pandemic, LPA Janet Tse conducted a tele inpsection and met with director Jeanine Rodrigues to continue investigation for the above allegation.

LPA observed seven children with one teacher, one teacher assistant, and the assistant director in the playground.

Through interviews and record reviews, LPA observed although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Director indicated a better plan of supervision will be implemented.

No deficiency was cited. Notice of site visit was issued and must be posted for 30 days.

This report with LPA's signature only will be emailed to the Director. In lieu of Director's signature, a read receipt of LPA's email will confirm acknowledgement of receipt of this report by Director.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/20/2020 and conducted by Evaluator Janet Tse
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20200220150146

FACILITY NAME:YWCA DAVIDSONFACILITY NUMBER:
430710536
ADMINISTRATOR:RODRIGUEZ, JEANINEFACILITY TYPE:
850
ADDRESS:375 SOUTH THRID STREETTELEPHONE:
(408) 295-4011
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:67CENSUS: 7DATE:
05/07/2020
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Jeanine RodriguezTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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9
Facility failed to submit incident report to the department.
INVESTIGATION FINDINGS:
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Due to the COVID-19 pandemic, LPA Janet Tse conducted a tele inpsection and met with director Jeanine Rodrigues to continue investigation for the above allegation. LPA observed seven children with one teacher, one teacher assistant, and the assistant director in the playground.

Through interviews and record reviews, LPA observed the incident was not reported to the Department in time as required. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12 & Chapter 1), are being cited on the attached LIC. 9099D.

Deficiency was cited. Notice of site visit was issued and must be posted for 30 days.

This report with LPA's signature only will be emailed to the Director. In lieu of Director's signature, a read receipt of LPA's email will confirm acknowledgement of receipt of this report by Director.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 07-CC-20200220150146
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: YWCA DAVIDSON
FACILITY NUMBER: 430710536
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2020
Section Cited
CCR
101212(d)
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Reporting Requirements. ...Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in
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Director shall submit a plan of correction to LPA by 05/21/2020 due date to explain how the center will develop a protocol for staffs to report the incidents to Licensing in time as required by Title 22.
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(d)(2) below shall be submitted to the Department within seven days following the occurrence of such event...
This requirement was not met as evidenced by:
LPA observed the incident was not reported to the Department in time as required.
This poses a potential risk to the Health, Safety, or Personal Rights of children 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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3