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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410606
Report Date: 11/09/2023
Date Signed: 11/16/2023 09:33:37 AM


Document Has Been Signed on 11/16/2023 09:33 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:SAN ANTONIO HEAD STARTFACILITY NUMBER:
434410606
ADMINISTRATOR:MARGARITA GONZALESFACILITY TYPE:
850
ADDRESS:1803 STOWE AVENUETELEPHONE:
(408) 573-4001
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY:40CENSUS: 16DATE:
11/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Gladys Eng, Site DirectorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Morales conducted a Case Management inspection to follow up on two Unusual Incidents that was reported by the facility to Licensing 5/31/23 and on 11/2/23. LPA was greeted by Site Director Gladys Eng. LPA toured the facility, interviewed staff, and obtained copies of documents.

Based on interviews and evidence gathered, it was determined that on May 31,2023, approximately at 10:30am (during transition to outdoor time), a Preschool aged child was left unattended inside the bathroom for approximately for five minutes in Classroom Number Two. This poses an immediate risk to the health, safety, and personal rights to children in care.

A Type A citation was issued at today's visit, and a copy of the Facility Evaluation Report LIC809/LIC809D, has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for the next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files. An exit interview was conducted, and Plan of Corrections were reviewed.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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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Document Has Been Signed on 11/16/2023 09:33 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: SAN ANTONIO HEAD START
FACILITY NUMBER: 434410606

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2023
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision(a)(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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 Site Director Gladys Eng conducted retraining and implemented additional steps June 9, and on August 7, 2023 on supervision and accountability with staff. No additional POC follow-up needed, corrections made by the facility following the incident.
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This requirement was not met as evidenced by: A child was left unattended inside Classroom Number Two's bathroom on May 31,2023. This poses an immediate risk to the health, safety, and personal rights to children in care.
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Upon receipt, Director shall post and provide copies of this licensing report, have LIC9224 signed and kept on file, to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months & copy of the signed acknowledgment form must be kept in each child's file.

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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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
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