<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410591
Report Date: 06/08/2023
Date Signed: 06/08/2023 10:59:59 AM


Document Has Been Signed on 06/08/2023 10:59 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:ORCHARD, THEFACILITY NUMBER:
434410591
ADMINISTRATOR:MARIA ROXANNE RESUMAFACILITY TYPE:
850
ADDRESS:494 S. BERNARDO AVE.TELEPHONE:
(408) 789-2621
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:58CENSUS: 22DATE:
06/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Pamela EricksonTIME COMPLETED:
11:15 AM
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
Licensing Program Analyst (LPA) Mel Matos met with Pamela Erickson, director, for an unannounced case management investigation. Purpose of today's investigation: discuss two incidents that the Facility self reported to the Department relating to a lapse of supervision.

The first incident occurred on May 3, 2023 involving a preschool child from the Clementine classroom. The preschool child was left unattended directly outside of the Clementine classroom for approximately five minutes during lunch time.

The second incident occurred on May 24, 2023 involving a preschool child from the Clementine classroom. The preschool child was left unattended in the bathroom in the Clementine classroom for a couple of minutes during pick up time.

LPA concludes that there was a lapse in supervision during both incidents of May 3, 2023 and May 24, 2023. A Type A deficiency is noted on the attached page (LIC 809-D) along with an immediate civil penalty of $500.00.

LPA Mel Matos, informed Director, Pamela Erickson, that this report dated June 8, 2023 documenting one Type A deficiency shall be posted for 30 consecutive days along with the notice of site visit as the Type A deficiency presents an immediate risk to the health, safety, or personal rights of children in care.

LPA Mel Matos also informed Director, Pamela Erickson, to provide a copy of this licensing report dated June 8, 2023 that documents the Type A citation 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 parents/guardians 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 placed in the child's file for verification.

LPA Matos advised Director, Pamela Erickson, that any repeat violation(s) within the next 12 months will result in additional civil penalties and a mandatory noncompliance meeting with Department management.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
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 2


Document Has Been Signed on 06/08/2023 10:59 AM - It Cannot Be Edited

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: ORCHARD, THE
FACILITY NUMBER: 434410591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2023
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision: No child(ren) shall be left without the supervision of a teacher at any time. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Director states that staff reviewed the supervision training materials after both incidents. Director states that a formal training for all staff is scheduled for Tuesday June 20, 2023.
8
9
10
11
12
13
14
On two separate dates (05/03/23 & 05/24/23), a child was left unsupervised in the Clementine classroom. This presents an immediate risk to the health, safety, or personal rights of children in care.
8
9
10
11
12
13
14
Director agreed to forward all training materials, including training agenda to LPA Matos by June 8, 2023 (COB).
An immediate civil penalty of $500 is assessed today and will accrue at $100 per day until this deficiency is corrected.

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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2