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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413745
Report Date: 06/12/2019
Date Signed: 06/12/2019 02:32:05 PM

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:CREATIVE HABITAT CHILDREN'S CENTERFACILITY NUMBER:
434413745
ADMINISTRATOR:CHIA-HSIU CHANGFACILITY TYPE:
830
ADDRESS:1190 WEST LATIMER AVENUETELEPHONE:
(408) 374-4442
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:24CENSUS: 16DATE:
06/12/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:36 AM
MET WITH:Christina PulidoTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Rangel, conducted an unannounced case management inspection in response to an unusual incidents that were reported on 6/12/19, 6/10/19, 6/3/19, 4/29/19 and 3/20/19 that the facility self reported to Community Care Licensing (CCL). LPA met with director Christina Pulido, and explained the nature of today's inspection to her.

During today's inspection LPA Rangel toured the facility, interviewed staff, and obtained copies of pertinent information.

Deficiency cited, exit interview conducted, and a copy of this report was provided to the facility.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE

SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CREATIVE HABITAT CHILDREN'S CENTER
FACILITY NUMBER: 434413745
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2019
Section Cited
CCR
101223(a)(2
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101223(a)(2) Personal Rights. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement was not met as evidenced by multiple children biting or attempting to bit each other at the Facility while the biting policy was being adjusted to fit the needs of the school.
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Licensee to submit a detailed plan of correction explaining what steps will be taken so that staff are better prepared to intervene to prevent incidences of this nature from occurring in the future. Plan to be sent to CCL by 6/13/19.
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This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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Updated biting policy to be sent to CCL by 6/19/19. The Licensee must provide copies of this report to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility during the next 12 months according with the AB633. LPA provided the Site Director with the AB633 fact sheet and the form LIC9224.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
LIC809 (FAS) - (06/04)
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