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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416999
Report Date: 04/20/2022
Date Signed: 04/20/2022 03:37:31 PM


Document Has Been Signed on 04/20/2022 03:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:CATALYST KIDS-LAKEWOODFACILITY NUMBER:
434416999
ADMINISTRATOR:KATHY ABADYFACILITY TYPE:
840
ADDRESS:750 LAKECHIME DRIVETELEPHONE:
(408) 769-4106
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:70CENSUS: 4DATE:
04/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Catelin KhayatanTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Mel Matos met with Catelin Khayatan, director, for an unannounced case management inspection. Purpose of today's inspection: investigate an Unusual Injury that was self reported to the Department.

Director states that the Unusual Injury occurred on March 7, 2022 in the outdoor playground area. Director states that a 10 year old school age slipped off the rock wall while the child was climbing the rock wall on the play structure. Director states that the child was trying to move out of another's child's way when the child slipped and fell off. Director states that the child fell about five feet and landed on the child's back on the padded playground surface.

Director states that the child got the "wind knocked out of her" as a result of the fall, but states that the child was able to walk over to the classroom. Director states that staff observed the incident & immediately tended to the child and applied ice to the child's back. Director states that the child's mother was called to come pick up the child. Director states that the child's mother picked up the child from the Facility and took the child to Kaiser the following day, March 8, 2022 for a check up. Director states that the child was checked and it was determined that the child did not have any fractures or injuries as a result of the child. Director states that the child returned to the Facility on March 9, 2022 and is doing fine.

LPA observed the play structure and rock wall during today's inspection and it is deemed safe and appropriate for school age children (grades 1 & 2). The resilient material (rubber tiles) underneath and surrounding the rock wall and play structure are sufficient.

It is concluded that the incident was an accident and not the direct result of unsafe/inadequate playground equipment & resilient materials; therefore, no deficiencies issued.

A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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