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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274400123
Report Date: 10/21/2024
Date Signed: 10/21/2024 04:28:35 PM

Document Has Been Signed on 10/21/2024 04:28 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SOLEDAD MIGRANT HEAD STARTFACILITY NUMBER:
274400123
ADMINISTRATOR/
DIRECTOR:		IBARRA, LETICIAFACILITY TYPE:
850
ADDRESS:160 MAIN STREETTELEPHONE:
(831) 678-1584
CITY:SOLEDADSTATE: CAZIP CODE:
93960
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 24DATE:
10/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Ana LucioTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Jimenez-Villanueva and Licensing Program Manager (LPM) Belinda Devall met to Ana Lucio Site Director to conduct an UNANNOUNCED CASE MANAGEMENT INSPECTION for a self reported Unusual Incident that occurred on September 16, 2024 where a child left the classroom and opened the gate to enter the gated hallway without permission from the teacher. Present during the inspection were 24 children and 5 Staff. Interviews and observations were conducted.

The facility has two classrooms in the front. There is a gated hallway in the corner of children area. This area is divided with a gate in the middle of the hallway. LPA conducted interview with Staff and the incident happened in the cleaning time and children were transitioning back and forth between the zone areas. All the teachers were instructing the children to clean up. Staff 1 was trying to separate two children that were disagreeing about putting the toys back and focusing their attention on the situation. Staff 2 was helping clean the floor with the children of things spilled on the floor. Staff 3 was cleaning with their children. A child left the classroom and two Education Specialist were leaving the facility from the other entry point into the gated hallway. The two stopped child from continuing to go through the gated hallway without the teachers. One of the Education Specialist called for Staff 3 to assist the child to the bathroom.

Based on the interviews conducted, a child left the classroom to go to the bathroom without supervision of a teacher. The child did not follow the protocols to inform the teacher their need to go to the bathroom. In addition, staff did not communicate for assistance when dealing with a different situation and unable to visually supervise the children in care. The following type B deficiency was cited on the attached page (809-D) and $500 civil penalty was assessed. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. Exit interview was conducted and 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.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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Document Has Been Signed on 10/21/2024 04:28 PM - It Cannot Be Edited


Created By: Martha Jimenez-Villanueva On 10/21/2024 at 02:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SOLEDAD MIGRANT HEAD START
FACILITY NUMBER: 274400123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2024
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual
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Director to submit a written plan and completed staff training on how staff will communicate changes for supervision of children in care when additional support is needed when staff cannot maintain visual supervision by the end of business day of 11/01/2024 to Regional Office.
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observation. This requirement was not met as evidenced by: a child left the classroom without visual suoervision of a teacher. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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:Susy Cervantes
LICENSING EVALUATOR NAME:Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
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