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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434416695
Report Date: 04/18/2022
Date Signed: 11/21/2022 11:49:48 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
03/14/2022 and conducted by Evaluator James G Santos
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20220314120232
FACILITY NAME:LITTLE OAK NURSERYFACILITY NUMBER:
434416695
ADMINISTRATOR:JENNIFER POTMESILFACILITY TYPE:
830
ADDRESS:1921 CLARINDA WAYTELEPHONE:
(408) 396-1252
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:30CENSUS: 11DATE:
04/18/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Jennifer Potmesil, DirectorTIME COMPLETED:
03:25 PM
ALLEGATION(S):
1
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9
Day care child sustained fracture while in care due to lack of supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), James Santos conducted an unannounced complaint inspection and met with Director, Jennifer Potmesil. The purpose of the inspection was to deliver the investigation finding for the above allegation.

The investigation of the above allegation was conducted by the Community Care Licensing Division (CCLD) Investigations Bureau. On 03/11/2022, C-1 was dropped off and walked into the classroom without issue per witness accounts. Staff were present in the classroom with three children when C-1 walked backwards on tippy toes and fell between a train table and an activity set in the center of the classroom. Staff stated the fall was observed and stated it seemed like "an ordinary fall.” C-1 refused to walk. There were no visual injuries to C-1, but C-1 flinched when the leg was touched. C-1 was transported to the hospital and was diagnosed with a nondisplaced spiral fracture of the distal tibia. Although there were two teachers present, and the teachers reported seeing the fall, the treating doctor felt the mechanism for the injury was inconsistent with the injury itself, therefore, this allegation is unsubstantiated.

Based on interviews, records reviewed, and evidence gathered during the investigation process, there is no preponderance of evidence that a day care child sustained a fracture while in care due to lack of supervision. Therefore, the allegation is UNSUBSTANTIATED.


NO DEFICIENCY WAS ISSUED. NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
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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