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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434413755
Report Date: 10/23/2019
Date Signed: 10/23/2019 05:20:28 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2019 and conducted by Evaluator Stephanie C Rangel
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20191018151003
FACILITY NAME:AFTER SCHOOL ADVENTURESFACILITY NUMBER:
434413755
ADMINISTRATOR:NASRIN ZARKUBFACILITY TYPE:
840
ADDRESS:1840 HARRIS AVENUE ROOM #31TELEPHONE:
(408) 264-8400
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:60CENSUS: 40DATE:
10/23/2019
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Nasrin ZarkubTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Cleaning supplies are not properly stored.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Stephanie Rangel and Nancy Rodriguez met with owner and director Nasrin Zarkub and explained the nature of today's inspection. Based on LPAs observations, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division& Chapter number), are being cited on the attached LIC 9099D.”)

NOTICE OF SITE VISIT WAS ISSUED AND A COPY OF THIS REPORT MUST BE POSTED FOR 30 DAYS.

Appeal rights printed and reviewed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 07-CC-20191018151003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: AFTER SCHOOL ADVENTURES
FACILITY NUMBER: 434413755
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2019
Section Cited
CCR
101238(g)
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Buildings and Grounds
Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.
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Licensee shall review regulations and submit a letter of understanding and a plan for how this deficiency will be avoided in the future by the POC date.
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This requirement was not met as evidenced by LPAs viewing cleaning products accessible to children. This poses a potential Safety risk to children in care.
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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: 10/23/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019
LIC9099 (FAS) - (06/04)
Page: 3 of 3