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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410766
Report Date: 12/12/2022
Date Signed: 12/12/2022 03:15:06 PM


Document Has Been Signed on 12/12/2022 03:15 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:ST JUSTIN PRESCHOOLFACILITY NUMBER:
434410766
ADMINISTRATOR:SHANNON BARELAFACILITY TYPE:
850
ADDRESS:2655 HOMESTEAD ROADTELEPHONE:
(408) 248-1094
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:51CENSUS: 30DATE:
12/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Shannon BarelaTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Anna Morales conducted a Case Management visit in regards to an Incident that occurred on 12/2/22 approximately at 3:30pm in the PRE-K(Classroom #5). The incident was reported to Community Care Licensing (CCL) on 12/5/2022. LPA was greeted by DIRECTOR Shannon Barela.. The hours of operation in Preschool and Pre-Kindergarten( Classroom Number 1) are from 8:00am-5:30pm.

On 12/2/2022, approximately at 3:30pm, (during snack time), S1 had observed C1 complaining of pain and scratching his/her left arm. S1 observed that C1 had dry skin and did not observe any visible injuries such as bruising or swelling. The Director stated that there were seven children and three staff present.

Approximately at 4:15pm, Director stated that the Preschool Classroom went into the Pre K (#1) classroom to watch a movie after playing outside. Director stated that the C1 did not complain of pain while playing outside and watching the movie. Approximately at 4:45pm both classrooms ( Preschool and Pre K) went to the Preschool Classroom for parent pick up. Director stated that C1's parent was notified that C1 had complained of pain, and had been scratching his/her left arm during pick up at 5:16pm.

On 12/5/22 at 8:05am, the Director stated that C1's Parent informed her that C1 had continued to complain of pain and was taken to the Emergency Room on 12/2/22. C1's parent informed the Director that no medical treatment was obtained, and C1 was able to return to school on 12/5/2022. C1's parent stated that C1 stated that S1 had pulled her/his arm. The Director stated that she conducted an internal investigation and interview staff. The Director stated that they did not observe any bruises or swelling when C1 left school on 12/2/22.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ST JUSTIN PRESCHOOL
FACILITY NUMBER: 434410766
VISIT DATE: 12/12/2022
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LPA interviewed the Director, S1, S2, and C1 and reviewed supporting documentation.

EXIT INTERVIEW WAS CONDUCTED AND REPORT WAS REVIEWED WITH THE DIRECTOR. NO DEFICIENCIES WERE CITED.

NOTICE OF SITE VISIT WAS GIVEN 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: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
LIC809 (FAS) - (06/04)
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