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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434415496
Report Date: 01/30/2020
Date Signed: 02/03/2020 10:21:03 AM



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
12/17/2019 and conducted by Evaluator Elizabeth Berumen
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20191217113316
FACILITY NAME:SJB-KENNEDY CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434415496
ADMINISTRATOR:MELISSA LEZAFACILITY TYPE:
850
ADDRESS:1602 LUCRETIA AVENUETELEPHONE:
(408) 414-2700
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:60CENSUS: 48DATE:
01/30/2020
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jessica MejiaTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility didn't notify parent of the incidents in writing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Elizabeth Berumen, conducted a follow up complaint inspection to the facility to deliver findings on above stated allegation. LPA met with Site Director, Jessica Mejia, and explained the nature of today's inspection to her. LPA obtained copies of pertinent information and conducted interviews.

In investigating the allegation noted above, LPA became aware that there were two incidents in which a preschool child sustained an injury that required medical attention. The Facility failed to file an Unusual Injury report with the Department as required per Title 22 regulations and also failed to report to the child's authorized representative.

Based on LPA's observations and interviews which were conducted and record review the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12 & Chapter 1), is being cited on the attached LIC. 9099D.
LPA provided Director Jessica Mejia with Appeal Rights.

NOTICE OF SITE VISIT WAS ISSUED AND SHALL BE POSTED FOR 30 DAYS.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
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
12/17/2019 and conducted by Evaluator Elizabeth Berumen
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20191217113316

FACILITY NAME:SJB-KENNEDY CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434415496
ADMINISTRATOR:MELISSA LEZAFACILITY TYPE:
850
ADDRESS:1602 LUCRETIA AVENUETELEPHONE:
(408) 414-2700
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:60CENSUS: 48DATE:
01/30/2020
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jessica MejiaTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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2
3
4
5
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8
9
Child injured at school twice
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA), Elizabeth Berumen , conducted an unannounced follow up complaint inspection to deliver findings. LPA met with Director, Jessica Mejia and explained the nature of today's inspection.

LPA Berumen conducted interviews, toured the facility and obtained copies of pertinent information. Throughout the investigation process, it was found the allegation (Staff failed to provide adequate supervison which resulted in child being injured at school twice) is unsubstantiated. Based on information obtained; there is not enough evidence to prove that the above allegation occurred. Due to the above information, the allegation is UNSUBSTANTIATED. A finding that is unsubstantiated means although the allegation may have happened or is valid , the preponderance of evidence does not prove it.

NOTICE OF SITE VISIT WAS ISSUED AND SHALL BE POSTED FOR 30 DAYS.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 07-CC-20191217113316
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: SJB-KENNEDY CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434415496
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2020
Section Cited
CCR
101212(f)
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Reporting Requirements
...The items specified in 101212(d)(1)(A) through (H) above shall also be reported to the child's authorized representative.
This requirement was not met as evidenced by:
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Director, Jessica Mejia agrees to submit a written plan of correction stating that she understands the requirement and include that she understands that the authorized representative must be notified regarding any unusual incidents in a timely manner. Plan of correction due date 02/06/2020.
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Facility failed to report to C1's authorized representative that C1 sustained injuries while at the center. The injuries required medical attention.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3