434414163-1-12-2023-07-CC-GKUN-CN8PHR-20230119102023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 434414163
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:22:59 PM

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
09/01/2022 and conducted by Evaluator Yangcheng Huang

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20220901092747

FACILITY NAME:	LITTLE TREE BILINGUAL MONTESSORI		FACILITY NUMBER:	434414163
ADMINISTRATOR:	Y FEN SHIH		FACILITY TYPE:	850
ADDRESS:	20111 STEVENS CREEK BLVD.#150&		TELEPHONE:	(408) 996-3399
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	125	CENSUS: 80	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Y Fen (Amanda) Shih		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Day care child sustained unexplained severe injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Oscar Huang met with Site Director, Y Fen (Amanda) Shih to deliver findings on the above allegation.

The investigation was conducted by IB Investigator, Victoria McIntosh. IB Investigator conducted interviews with director, staff, parents of child in care, children in care, as well as reviewed hospital medical records, unusual incident report, and children records during the investigation of the allegation. On 8/30/2022, at the time the incident occurred there was a staff supervised 12 children. Statement of confidential interviews with staff and children in the classroom were consistent that the staff was preoccupied by applying sunscreen to other children without witnessing C1's fall while C1 was swinging in between two desks, tripped on C1's dress caused to fall, and sustained injuries to C1's chin & mouth.

Continue to next page LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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-20220901092747

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: LITTLE TREE BILINGUAL MONTESSORI	FACILITY NUMBER: 434414163
	VISIT DATE: 01/12/2023

NARRATIVE

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IB Investigator concludes that based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Director was informed that civil penalties may be assessed by the department determined that any violation resulted into injury of a person in care, and/or failure to correct the deficiency.

LPA advised director that a schedule informal meeting will be held at the San Jose Regional office to discuss the deficiency.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

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Control Number 07-CC-20220901092747

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: LITTLE TREE BILINGUAL MONTESSORI	FACILITY NUMBER: 434414163
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 01/23/2023 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision - No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.	1 2 3 4 5 6 7	Director to submit CCL plan of correction in written indicating methods and procedures implemented to ensure the facility stays in compliance with Tittle 22, Care and Supervision regulations, as well as to schedule a title 22 supervision training focus on supervision and visual observation for all staff to ensure this will not occurred going forward.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: A child tripped on their dress while swinging between two desks, causing they to fall and sustain injuries, the teacher was not observing while busy applying sunscreening to other children. This poses an immediately safety & health risk to children in care.	8 9 10 11 12 13 14	A copy of agenda including names and signatures of staff of attendance, shall also be sent to CCL prior to the POC due date. According to AB 633, all parents of children currently enrolled and any future children being enrolled for the next 12 months must be provided with this report which contains this type A deficiency.
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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: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

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