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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413755
Report Date: 10/05/2022
Date Signed: 10/05/2022 03:08:33 PM


Document Has Been Signed on 10/05/2022 03:08 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



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: 0DATE:
10/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Nasrin ZarkubTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), James Santos conducted an unannounced case management visit today and met with Licensee, Nasrin Zarkub. The purpose of today's visit was in regards with the incident reported to CCL on 9/21/2022 involving two children. Licensee sent the Unusual Incident Report and also called the SJRO.

Per incident report, on 9/20/2022 at around 2:15pm, a parent from the elementary school went to the after school facility with her daughter and asked the Licensee if she can speak to one of their day care child (C1). Licensee asked the parent why she would like to talk to the day care child (C1) and the parent told Licensee that C1 pushed her daughter. Licensee told the parent that if she has any complaints, she has to go to the elementary school office and also speak to her daughter's teacher.

Per Licensee, she asked C1 if he pushed the other child and C1 stated no. After the elementary school parent left, Licensee notified C1's parent about the incident. Per Licensee, on 9/21/2022, the elementary school principal told her that he spoke to both children's parents in regards with the incident.

Per Licensee, the alleged incident happened in the elementary school during regular school hours, not during after school care. Both children are kindergarten students in the elementary school but only C1 goes to the after school day care. The elementary school and the after school license facility are both located on the same property compound.

No deficiencies cited. Exit interview conducted and report was reviewed and a copy of this report was provided to Licensee, Nasrin Zarkub.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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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