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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434415832
Report Date: 01/10/2022
Date Signed: 01/10/2022 11:08:56 AM

Unsubstantiated


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
10/14/2021 and conducted by Evaluator Melvin S Matos
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20211014145110
FACILITY NAME:SJB-ROULEAU CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434415832
ADMINISTRATOR:NATIVIDAD DE LA ROSAFACILITY TYPE:
850
ADDRESS:1875 MONROVIA DRIVETELEPHONE:
(408) 573-4713
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:16CENSUS: 6DATE:
01/10/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Linda AdamsTIME COMPLETED:
11:25 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Daycare child sustained unexplained injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Mel Matos & Cortney Nelson conducted an unannounced follow up complaint investigation and met with Linda Adams, director. Purpose of today's follow up complaint investigation: deliver investigation findings.

The investigation of the complaint allegation listed in this complaint was conducted by LPA Janette Cruz. Based on evidence gathered, including record/document reviews, and interviews completed for the complaint investigation, it is concluded that although the allegation noted on this complaint may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. The allegation is thus UNSUBSTANTIATED.
A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
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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