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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410591
Report Date: 06/14/2024
Date Signed: 06/14/2024 11:33:12 AM


Document Has Been Signed on 06/14/2024 11:33 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:ORCHARD, THEFACILITY NUMBER:
434410591
ADMINISTRATOR:PAMELA ERICKSONFACILITY TYPE:
850
ADDRESS:494 S. BERNARDO AVE.TELEPHONE:
(408) 789-2621
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:58CENSUS: 27DATE:
06/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maria Roxanne ResumaTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mel Matos met with Maria Roxanne Resuma, infant director, for an unannounced case management investigation. Purpose of today's investigation: Investigate an Unusual Incident that the Facility self reported to the Department on June 12, 2024.

Maria Roxanne states that the incident occurred in the Fig Room on Thursday June 6, 2024 between 3:15 and 3:30 PM. Maria Roxanne states that two teachers were outside in the preschool playground setting up for graduation and two teachers were inside the Fig Room with 14 preschool children. Some of the preschool children were waking up from nap and the required ratio inside the classroom was 1:12. Maria Roxanne states that one teacher inside the Fig Room left the other teacher alone in the classroom with 14 preschool children between 3:15 PM and 3:30 PM (15 minutes) on Thursday June 6, 2024. The one teacher inside the Fig Room did not immediately request for assistance since the teacher was assisting children who were waking up from nap. The teacher did request assistance after 15 minutes and the preschool director immediately came to the classroom to cover ratio.

Maria Roxanne states that there is normally three to four staff in the Fig Room and ratios are 1:6 or less due to current low enrollment. Maria Roxanne states that sufficient staff were on site on June 6, 2024; however, some staff were outside in the preschool playground setting up for graduation at the time of incident.

Based on the available evidence, it is concluded that the Fig Room was out of ratio from 3:15 PM to 3:30 PM on Thursday June 6, 2024 when one teacher was alone in the Fig Room with 14 preschool children.

This presents a potential health & safety risk and thus a "Type B" deficiency is cited on the attached page (809-D). Exit interview conducted and report was reviewed with the infant director, Maria Roxanne Resuma, and copy of appeal rights was provided. A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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 06/14/2024 11:33 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ORCHARD, THE
FACILITY NUMBER: 434410591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
101216.3(a)

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Teacher-child ratio: There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.
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Maria Roxanne, infant director, agreed to submit a written Plan of Correction (POC) outlining the procedures that will be implemented to ensure that the Facility is in compliance with the required
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This requirement was not met as evidenced by: the Fig Room was out of ratio from 3:15 PM to 3:30 PM on Thursday June 6, 2024 when one teacher was alone in the Fig Room with 14 preschool children. This presents a potential risk to the health, safety or personal rights of children in care.
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teacher-child ratios at all times.

Plan of Correction due to LPA Matos by Friday June 21, 2024.

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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: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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