430752951-12-19-2022-07-CC-ASTR-CM9P7B-20221219100340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430752951
Report Date: 08/30/2022
Date Signed: 12/19/2022 09:56:57 AM

Substantiated

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
02/23/2022 and conducted by Evaluator Samantha Yip

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20220223161427

FACILITY NAME:	GOULARTE, PATTY		FACILITY NUMBER:	430752951
ADMINISTRATOR:	GOULARTE, PATTY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 683-2738
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY:	12	CENSUS: 0	DATE:	08/30/2022
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:			TIME COMPLETED:	09:49 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Day care child was sexually abused by an adult in the home.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 08/30/2022, Regional Manager (RM) Tony Studebaker and Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Complaint Investigation to deliver complaint findings regarding the allegation listed above. LPA and RM were unable to gain access to the residence so the Complaint Investigation Report (LIC 9099), Deficiency Report (9099-D), and Confidential Names (LIC 811) will be provided to the Licensee via mail.

------------------continues on 9099 dated 08/30/2022 page 2------------------------

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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

Control Number 07-CC-20220223161427

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: GOULARTE, PATTY	FACILITY NUMBER: 430752951
	VISIT DATE: 08/30/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

------------------continuation of 9099 dated 08/30/2022 page 1--------------------

The Department investigated the allegation and determined that an adult in the home, Harry Goularte, sexually abused C-1 while in care. Licensee was notified that Harry was served with an immediate exclusion order on February 28, 2022. Per the Licensee, facility is not currently operating. Based on the information obtained during the investigation, the above allegation is found to be SUBSTANTIATED, meaning the preponderance of the evidence standard has been met.

Licensee is informed to provide a copy of this licensing report documenting a Type A deficiency to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled child’s parent/guardian for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be place in the child’s file for verification.

As a result of this inspection, a Type A deficiency was issued. A Notice of Site Visit (LIC 9213) was provided and must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Department requests that the Licensee sign and return the LIC 9099 and LIC 9099-D page by Friday, October 14th, 2022. Documents should be sent to the San Jose Child Care Regional Office located at 2580 N. First Street, Suite 300, San Jose, CA 95131.

Enclosures: LIC 9099, LIC 9099-D, LIC 811, LIC 9224, LIC 9213, LIC 9058.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 07-CC-20220223161427

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: GOULARTE, PATTY	FACILITY NUMBER: 430752951
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/30/2022 Section Cited CCR 102423(a)(4)	1 2 3 4 5 6 7	Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning. This requirement is not met as evident by:	1 2 3 4 5 6 7	Adult was served with an Immediate Exclusion, removed from the home, and per Licensee day care is not in operation at this time.
	8 9 10 11 12 13 14	Based on record reviews and interviews, adult in the home sexually abused C-1 while in care, which posed an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3