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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274416181
Report Date: 04/02/2024
Date Signed: 04/03/2024 08:51:55 AM

Document Has Been Signed on 04/03/2024 08:51 AM - 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:POTRERO CANYON SCHOOL LLCFACILITY NUMBER:
274416181
ADMINISTRATOR:ANDRA BRIANTFACILITY TYPE:
850
ADDRESS:5716 CARMEL VALLEY ROADTELEPHONE:
(831) 625-0545
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 21DATE:
04/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Andra BriantTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Cortez and Licensing Program Manager (LPM) Gladys Kuizon conducted an unannounced Case Management Inspection at the facility today and met with Director Andra Briant .

LPA and LPM arrived 10:17AM and observed 4 staff and 21 children.

The purpose of today's visit is to investigate an incident that occurred on 02-13-2024. Facility self reported an incident 02-13-2024 where child (C1) was left unattended in room 1 for 5-7 minutes. C1 was in a secured room sitting in the corner until found by staff. C1 was not injured during this incident. LPA and LPM interviewed Director. Director stated staff training was completed and an Individual Development Plan was completed and discussed with staff (S1).

A Notice of Site Visit has been issued and must remain posted for 30 consecutive days.

A Deficiency has been cited as a result of today's inspection. Please refer to page 809-D for citation, description, and plan of correction. LPA discussed the requirements of AB633 to Director Andra Briant and provided a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). Exit interview conducted with Director Andra where this report was reviewed and a copy of appeal rights was provided.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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 04/03/2024 08:51 AM - It Cannot Be Edited


Created By: Andrea Cortez On 04/02/2024 at 11:31 AM
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: POTRERO CANYON SCHOOL LLC
FACILITY NUMBER: 274416181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/03/2024
Section Cited
CCR
101229(a)(1)

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Care and Supervision
No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).
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Written plan of action completed on 2-16-2024 and reviewed today.
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This requirement was not met as evidenced by: Based on written report and interview with Director, C1 was left unattended in Room 1 on 02-13-24. This poses an immediate safety risk to C1.
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Andrea Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024


LIC809 (FAS) - (06/04)
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