434414060-5-3-2023-07-CC-DSTN-CSLSNZ-20230608140221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 434414060
Report Date: 05/03/2023
Date Signed: 05/03/2023 10:44:59 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 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
04/28/2023 and conducted by Evaluator Kassandra Medrano

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20230428164813

FACILITY NAME:	JORDAN, ELIZABETH		FACILITY NUMBER:	434414060
ADMINISTRATOR:	JORDAN, ELIZABETH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 281-7855
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	14	CENSUS: 2	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Elizabeth Jordan		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility is Disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kassandra Medrano made an unannounced initial10-day visit and met with Licensee, Elizabeth.The purpose of the inspection was explained. LPA Medrano toured the facility and inspected the home for health and safety hazards. Present in the home were licensee, two children, and adult daughter, Makaylah.
Based on observations and interviews; the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. LPA discussed the mattress in the front yard, as well as the overall cleanliness of the entry way. Although, the front yard is an off limits area, it is important to maintain a presentable yard. As well as the back yard fence, the licensee stated she has had problems with her fence since the stroms, and has been trying to work with her neighbors to fix it. LPA observed one plank loose, and a lean to the fence. LPA did not observe any immediate danger or ability for children to exit through loose plank. A finding that is substantiated means the preponderance of evidence was found.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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-20230428164813

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JORDAN, ELIZABETH	FACILITY NUMBER: 434414060
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/10/2023 Section Cited CCR 102417(b)	1 2 3 4 5 6 7	Operation of a Family Child Care Home The home shall be kept clean and orderly.... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated she will send picture documentation of board on fence corrected, as well as photo documentation of of the front yard with objects removed.
	8 9 10 11 12 13 14	Based on observations and conversations with licensee, LPA observed the fence with a lean and a loose plank, as well as objects in the front yard that did not belong. This poses a potential health and safety risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC9099 (FAS) - (06/04)

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