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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400032
Report Date: 09/28/2022
Date Signed: 09/28/2022 10:24:52 AM


Document Has Been Signed on 09/28/2022 10:24 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:CALIFORNIA YOUNG WORLD AT SAN MIGUELFACILITY NUMBER:
434400032
ADMINISTRATOR:EMERSON VENTURAFACILITY TYPE:
840
ADDRESS:777 SAN MIGUEL AVENUETELEPHONE:
(408) 738-1385
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:28CENSUS: 0DATE:
09/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Emerson VenturaTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Mel Matos met with Emerson Ventura, Director, for an unannounced case management inspection. Purpose of inspection: investigate an Unusual Incident that the Facility self reported to the Department.

The Unusual Incident occurred on May 20, 2022 at 7:15 AM when two school age children walked out of the classroom (Portable 2) with the intention of walking to the home of one of the school age children to pick up that child's IPad. Emerson states that a school age teacher who was arriving at the Facility at the same time observed the two school age children outside the classroom. Emerson states that the teacher talked with the two school age children and brought them back to the classroom (Portable 2).

Emerson states that he talked to the children and staff about supervision and that children cannot leave the Facility on their own. Emerson states that the parents of both children were also notified about the incident. Emerson states that both children are still enrolled at the Facility.

Exit interview conducted and report was reviewed with the director, Emerson Ventura. No deficiencies issued during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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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