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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703885
Report Date: 03/22/2023
Date Signed: 03/22/2023 03:20:20 PM

Document Has Been Signed on 03/22/2023 03:20 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:CALIFORNIA YOUNG WORLD # 5FACILITY NUMBER:
430703885
ADMINISTRATOR:ANGEL TORNOFACILITY TYPE:
850
ADDRESS:1110 FAIRWOOD DRIVETELEPHONE:
(408) 245-7285
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY: 104TOTAL ENROLLED CHILDREN: 48CENSUS: 40DATE:
03/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Angel TornoTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Mel Matos met with Angel Torno, director, for an unannounced case management investigation. Purpose of today's investigation: discuss unusual incident that the Facility self reported to the Department.

Angel states that the incident occurred on December 8, 2022 at 3:50 PM on the preschool playground. Angel states that there were 20 preschool children with four staff (from Rooms 5 & 6) in the preschool playground at the time of the incident. Angel states that three preschool children from Room 6 were playing with a rubber kick ball in preschool playground. Angel states that one of the preschool children did not want to share the ball with the other two preschool children.

Angel states that the other two preschool children proceeded to kick and hit the one preschool child while the child was on the ground with the ball. Angel states that one teacher and the child's mother (child who was kicked and hit) observed the incident and the preschool children were immediately separated. Angel states that the child's mother brought the child to the office and spoke with Angel about the incident. Angel states that the preschool child had some scrapes on the right side of the child's face and right ear. Angel states that the preschool child was not upset or crying as a result of the incident.

Angel states that she spoke with the staff who were in preschool playground as well as the two other preschool children. Angel states that she reminded all staff to be more vigilant and aware of their surroundings to avoid any repeat incident(s) in the future. Angel states that there were no prior incidents. Angel states that the preschool child who was hit was taken to see a doctor by the child's mother and states that the child did not require any medical attention. Angel states that the child is doing fine and has returned to the program.

Based on the available evidence, it is concluded that the incident which occurred on December 8, 2022 was not a direct result of lack of supervision and thus no deficiencies issued. Exit interview conducted with Angel Torno, director, and a copy of today's report was reviewed/provided to her. Notice of site visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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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