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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410591
Report Date: 04/20/2022
Date Signed: 04/20/2022 01:22:43 PM


Document Has Been Signed on 04/20/2022 01:22 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:ORCHARD, THEFACILITY NUMBER:
434410591
ADMINISTRATOR:ELIZABETH "OMI" LINDSEYFACILITY TYPE:
850
ADDRESS:494 S. BERNARDO AVE.TELEPHONE:
(408) 789-2621
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:58CENSUS: 39DATE:
04/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elizabeth "Omi" LindseyTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Mel Matos met with Elizabeth "Omi" Lindsey, director, for unannounced case management inspection. Purpose of today's inspection: investigate an Unusual Injury that was self reported to the Department.

Director reported that the Unusual Injury occurred on March 8, 2022 in the Nutmeg Room. Director states that one preschool child tripped on an area rug while walking towards the bathroom causing the child to hit the child's left eyelid/brow area on a wood chair. Director states that there were three staff in the classroom at the time of the incident. Staff tended to the child by washing, bandaging, and icing the affected area. Director states that the child did sustain a cut and bruise as a result of the incident.

Director states that the child's parents were called and the child was picked up shortly after the incident. Director states that the child's parents took the child to a doctor (Director does not recall name or location) and the child's injury was glued and bandaged. Director states that the child was back at the Facility the following day and is doing fine. Director states that staff toured the room after the incident to check for any potential tripping/safety hazards and none were found.

LPA toured the Nutmeg Room with Omi during today's inspection and observed the area where the incident occurred on March 8, 2022. LPA observed that the rugs and chairs inside the Nutmeg room area do not present any hazard/risk to children or staff.

It is concluded that the incident was an accident and not the direct result of the Facility having unsafe rugs & chairs inside the classroom; therefore, no deficiencies issued.

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: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
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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