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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434416162
Report Date: 02/28/2024
Date Signed: 02/28/2024 09:46:06 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
11/30/2023 and conducted by Evaluator Melvin S Matos
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20231130090134
FACILITY NAME:HACIENDA HI-FIVE AFTER SCHOOL CLUBFACILITY NUMBER:
434416162
ADMINISTRATOR:DEBANJALI BANERJEEFACILITY TYPE:
840
ADDRESS:1290 KIMBERLY DRIVETELEPHONE:
(408) 568-3674
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:120CENSUS: 22DATE:
02/28/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Arulkumar SundarramanTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unqualified staff caring for day care children
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Mel Matos conducted an unannounced follow-up complaint investigation and met with Arulkumar Sundarraman, Licensee representative/temporary director. Purpose of today's follow up complaint investigation: deliver investigation findings.
The investigation of the complaint allegation listed above was conducted by LPA Matos. Based on interviews, record reviews, observations, and evidence gathered during the investigation process, it is concluded that although the allegation noted on this complaint may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is thus UNSUBSTANTIATED.
A Notice of Site Visit was provided to Arulkumar Sundarraman, Licensee representative/temporary director, 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: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
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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