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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434415720
Report Date: 07/11/2023
Date Signed: 07/11/2023 12:13:54 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
06/05/2023 and conducted by Evaluator Pietro Hernandez
COMPLAINT CONTROL NUMBER: 07-CC-20230605101140
FACILITY NAME:LAUREL PLAYGARDENSFACILITY NUMBER:
434415720
ADMINISTRATOR:KRISTINA SORENSEN MUSGRAVEFACILITY TYPE:
850
ADDRESS:1050 PARK AVENUETELEPHONE:
(408) 645-5783
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:47CENSUS: 27DATE:
07/11/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:SOUVANNARY THONGMANIVONGTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Neglect/Lack of supervision resulting in child sustaining a fracture while in care

Staff did not provide a safe environment for daycare children

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pete Hernandez conducted an unannounced subsequent complaint visit to deliver findings for the allegations reported above. LPA met with Director Souvannary Thongmanivong and explained the purpose of the visit.

On 6/14/2023 LPA Pete Hernandez conducted staff interviews and reviewed on line documentation related to the equipment used to determine the manufacture's age recommendations. LPA was provided a copy of the children's roster. According to the manufacturers recommentations, it was determined that the equipement was not age appropriate.

Based on LPAs observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Continued on page 2 of 9099C dated 7/11/2023.
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Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
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 5
Control Number 07-CC-20230605101140
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: LAUREL PLAYGARDENS
FACILITY NUMBER: 434415720
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2023
Section Cited
CCR
101223(a)(2)
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Personal Rights 101223: (a) The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement has not been met as evidenced by:
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By the POC date: The Licensee shall submit a plan of correction to CCLD outlining how the facility will prevent future injuries to the children who use this exercise equipement and insure that the manufacture's recommendations are followed.
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Based on interviews and records, the facility failed to provide a safe environment and was neglectful of C1’s needs by allowing C1 to play in a structure that is not age appropriate. This posed an immediate risk to C1’s health and safety. This poses an immediate risk to the health and safety of children in care.
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Upon receipt, Licensee shall have all parents signt LIC9224 and retain a copy in the children's files AND licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.
Type B
07/18/2023
Section Cited
CCR
101239(m)
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101239(m): Fixtures, Furniture, Equipment, and Supplies 101239(m) All play equipment and materials used by children shall be age-appropriate. This requirement has not been met as evidenced by:
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By the POC date: The Licensee shall submit a plan of correction to CCLD outlining how the facility will impliment a procedure to follow manufacturers guidelines and age requirements.
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Based on interviews and records, the facility’s Railyard exercise course is intended by the manufacturer to be used for children ages 5 and up. The facility allowed children younger than 5, including C1, to use the exercise course. This poses a potential risk to the health and safety of 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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/05/2023 and conducted by Evaluator Pietro Hernandez
COMPLAINT CONTROL NUMBER: 07-CC-20230605101140

FACILITY NAME:LAUREL PLAYGARDENSFACILITY NUMBER:
434415720
ADMINISTRATOR:KRISTINA SORENSEN MUSGRAVEFACILITY TYPE:
850
ADDRESS:1050 PARK AVENUETELEPHONE:
(408) 645-5783
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:47CENSUS: DATE:
07/11/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:SOUVANNARY THONGMANIVONGTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not seek medical attention for child in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pete Hernandez conducted an unannounced subsequent complaint visit to deliver findings for the allegation reported above. LPA met with Director Souvannary Thongmanivong and explained the purpose of the visit.
On 6/14/2023 LPA Pete Hernandez conducted staff interviews and reviewed documentation privided by the Licensee and reporting party (RP). LPA was provided a copy of the children's roster, sign in and sign out sheets, and ouch report.
The investigation revealed that child C1 sustained a fracture after falling from schoolyard equipment. The facility treated the injury with ice and contacted the parents within 20 minutes. The Licensee contacted the child's mother offered to call an ambulance and the mother declined. She chose to pick up the child instead. The child was treated for the injury at the hospital after pick up where the child was treated for his injury. According to C1’s mother, the treating physician suggested that it is possible that the fracture was not immediately displaced and improper handling and movements may have caused the bone to shift and be displaced.
Continued on page 2 of 9099C dated 7/11/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 07-CC-20230605101140
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: LAUREL PLAYGARDENS
FACILITY NUMBER: 434415720
VISIT DATE: 07/11/2023
NARRATIVE
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Based on interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED NEAR OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 07-CC-20230605101140
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: LAUREL PLAYGARDENS
FACILITY NUMBER: 434415720
VISIT DATE: 07/11/2023
NARRATIVE
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Allegation 1) Neglect/Lack of supervision resulting in child sustaining a fracture while in care:

Based on the interviews, there were staff present at the time of the incident involving child, C1, and the incident was observed. The equipment "Railyard exercise course" that C1 was allowed to play on was age inappropriate. The online Railyard user manual states "All exercises are designed for ages 5 and up. For children, early success followed by continually progressive challenge is the most effective way to learn something new. Therefore, we have ensured that all the movements can be modified to accommodate each skill and developmental level from 5 years of age and up." C1 was under 5 at the time of the injury. The recommended use of the manufacturer was not followed. The equipment was also modified to a more advanced level to an unsafe height for young children even if there were padding under the equipment. Since this was age inappropriate for the child injured and there was a lack of risk assessment, even though they were supervised it was neglect on behalf of the facility that resulted in the child being injured. This allegation is substantiated.

Allegation 2) Staff did not provide a safe environment for daycare children.

LPA observed the equipment and the manufacturer's recommended age and use. The child (C1) that sustained an injury was under the recommended age. The equipment was not age appropriate. Therefore, this is substantiated.

An issuance of Type A citations today, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.



A deficiency is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC9099D. An exit interview was conducted, and Plan of Corrections were reviewed and developed with the licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Souvannary Thongmanivong, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED NEAR OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5