434415739-11-28-2022-07-CC-JSEA-CNGVGR-20230127152558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 434415739
Report Date: 11/28/2022
Date Signed: 11/28/2022 04:41:09 PM

Substantiated

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
11/21/2022 and conducted by Evaluator Samantha Yip

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20221121124310

FACILITY NAME:	SJB - ANTONIO DEL BUONO CDC		FACILITY NUMBER:	434415739
ADMINISTRATOR:	PATRICIA KEITH		FACILITY TYPE:	850
ADDRESS:	245 FARRELL AVENUE		TELEPHONE:	(408) 414-2700
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	44	CENSUS: 25	DATE:	11/28/2022
		UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Patricia "Patty" Keith and Maria Velazquez		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff denied child's authorized person access to information regarding child's care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced complaint investigation. LPA met with Site Director Patricia "Patty" Keith and explained the reason for the inspection. Regional Manager, Maria Velazquez, arrived shortly after. Present during today's inspection were 25 children and at least 4 staff.

During today's inspection, LPA reviewed pertain documents and interviewed staff. Based on the information obtained, the above allegation was found to be SUBSTANTIATED, meaning the preponderance of the evidence standard has been met.
------------------continuation of 809 dated 11/28/2022 page 2----------------------

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

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

Control Number 07-CC-20221121124310

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 - ANTONIO DEL BUONO CDC	FACILITY NUMBER: 434415739
	VISIT DATE: 11/28/2022

NARRATIVE

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-----------------continuation of 9099 dated 11/28/2022 page 1-----------------------

Based on email correspondence, the parent requested incident reports and enrollment agreement from the facility. Facility did not provide a copy of the incident report until 11/23/2022. Facility received a copy of the court order on request for documents from the parent on 03/22/2022. The parent was added as an authorized representative on 04/18/2022.

As a result of this investigation, a Type B citation was issued. Exit interview was conducted and report was reviewed with Site Director Patricia "Patty" Keith and Regional Manager Maria Velazque. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 07-CC-20221121124310

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 - ANTONIO DEL BUONO CDC	FACILITY NUMBER: 434415739
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/05/2022 Section Cited CCR 101221(e)	1 2 3 4 5 6 7	Child's Records. A child's records shall also be open to inspection by the child's authorized representative. This requirement is not met as evident by:	1 2 3 4 5 6 7	By POC 12/05/2022, facility will send written statement stating that they understand that child's records are open to inspection by the child's authorized
	8 9 10 11 12 13 14	Based on record reviews, parent requested documents, such as enrollment agreement and incident reports. Parent was added as a authorized representative on 04/18/2022. Facility provided documents to parent on 11/23/2022. This poses a potential risk to the health and safety to the children in care.	8 9 10 11 12 13 14	representative.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC9099 (FAS) - (06/04)

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