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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 350709612
Report Date: 12/02/2024
Date Signed: 12/02/2024 12:46:47 PM

Document Has Been Signed on 12/02/2024 12:46 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:HOLLISTER HEAD STARTFACILITY NUMBER:
350709612
ADMINISTRATOR/
DIRECTOR:		ROCIO LITLEFACILITY TYPE:
850
ADDRESS:1011 LINE STREETTELEPHONE:
(408) 637-8597
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 77TOTAL ENROLLED CHILDREN: 60CENSUS: 50DATE:
12/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Martha, MoralesTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 12/2/24, at 9:40 AM, Licensing Program Analyst (LPA) arrived unannounced to conduct a Case Management inspection. LPA met and was greeted by Director, Morales, Martha and informed her today’s purpose of inspection. LPA observed three (3) classrooms, Hollister room 1 with 16 children, lead teacher and 2 associate teachers, Hollister room 2 with 17 children and 3 associate teachers, and Hollister room 7 with 17 children and 3 associate teachers.

During visit, LPA interviewed a teacher regarding an incident that occurred on 11/19/2024 with another child. Staff informed LPA on 11/19/2024, approximately 10:30AM, C1 was playing with his friends and was being chased by another child and C1 was not looking in front of him and he ran into another child that was playing on the floor and fell onto the concrete. Mrs. Garcia, Belinda, teacher, witnessed the incident and attended to C1. Mrs. Belinda assisted C1 with first aid by applying an ice pack to the knee/ankle and teacher monitored C1. Teacher notified C1’s ankle was hurting because he was limping on it. Around 12pm, children were being transitioned to nap time and C1 took a nap. Around 1:45 PM, Mrs. Belinda asked what is hurting and C1 stated his ankle hurts. C1’s father was waiting outside the class at 1:50PM and staff informed parent after C1 was picked up from school about the incident that happened.

LPA asked Mrs. Belinda if you or other staff informed parents about the that incident occurred and staff stated no, parents were not informed until pick up time.


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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: HOLLISTER HEAD START
FACILITY NUMBER: 350709612
VISIT DATE: 12/02/2024
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The following type B deficiency was cited on the attached page (809-D). Licensee was informed that failure to correct the deficiency 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.

A Notice of Site Visit was given and must remain posted for 30 days.

Exit interview conducted with director, and a copy of this report review and provided along with appeal rights.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2024 12:46 PM - It Cannot Be Edited


Created By: Liridon Fici On 12/02/2024 at 12:30 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: HOLLISTER HEAD START
FACILITY NUMBER: 350709612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2024
Section Cited
CCR
101226(a)

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101226(a): Health related Services: (a) The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch...

This requirement is not met as evidenced by:
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Director stated, she will meet with all preschool staff to discuss reporting requirements and to report all types of incidentes to director and parents that occur at the center. Director mentioned that all staff will review the centers accident report form, and how to properly fill it out.
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 Based on interview conducted, the licensee did not comply with the section cited above by not reporting C1's serious injury (ankle) to C1's representatives which poses a potential health, safety, or personal rights risk to persons 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:Gladys Kuizon
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024


LIC809 (FAS) - (06/04)
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