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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710093
Report Date: 12/18/2025
Date Signed: 12/18/2025 12:09:35 PM

Document Has Been Signed on 12/18/2025 12:09 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:LYNDALE HEAD STARTFACILITY NUMBER:
430710093
ADMINISTRATOR/
DIRECTOR:		ELISA HERNANDEZFACILITY TYPE:
850
ADDRESS:13901 NORDYKE DRIVETELEPHONE:
(408) 258-1523
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 48TOTAL ENROLLED CHILDREN: 26CENSUS: 28DATE:
12/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Born, RoopaliTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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On 12/18/2025, at 8:50 AM, Licensing Program Analyst (LPA) Liridon Fici- Doni conducted an unannounced Case Management visit regarding an incident that occurred on 12/12/2025 and met with Born, Roopali- Director and informed her the purpose of today's visit. LPA observed 28 children in care.

During today's visit, LPA obtained copies of children's roster for 12/12/2025 and current children's roster for 12/18/2025 and interviewed three (3) children and director. On 12/12/2025, the Director stated she was in her office when Staff 2 (S2) informed her that Child 1 (C1) had diarrhea and did not have extra clothing. The Director contacted the parents to request additional clothing along with leaving a voice message. The Director made the call herself so that S2 could continue supervising the children. C1 and S2 later went outside. The Director attempted to contact the parents; however, there was no answer.

Director stated that, in the meantime, she went next door to check for extra clothing, but none was available. The Director also checked the playhouse and did not find any clothing to provide for the child. The Director then planned to go to Target to purchase clothing for C1. While walking toward the front door, the Director was informed by Staff 3 (S3) after C1 went home that C1’s parent had observed C1 playing outside in underwear and was upset.

The Director returned to the classroom and observed C1’s parent present with extra clothing for the child. The parent informed the Director that she was upset that C1 had been outside wearing only underwear. The Director stated she was not aware that C1 had been taken outside without clothing. The parent expressed continued concern and decided to take C1 home.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Liridon Fici
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: LYNDALE HEAD START
FACILITY NUMBER: 430710093
VISIT DATE: 12/18/2025
NARRATIVE
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The Director stated that upper management and Human Resources (HR) were informed of the incident and that S2 was placed on leave while an internal investigation is ongoing. The Director also stated she plans to conduct additional training regarding children’s personal rights and will remind all staff to inform parents to provide extra clothing for children in care to prevent similar incidents in the future.

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 and report was reviewed with the Director, Born, Roopali, along with appeal rights provided.















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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Liridon Fici
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/18/2025 12:09 PM - It Cannot Be Edited


Created By: Liridon Fici On 12/18/2025 at 11:35 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: LYNDALE HEAD START
FACILITY NUMBER: 430710093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/25/2025
Section Cited
CCR
101223(a)(1)

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101223(a)(1)- Personal Rights: (a) The licensee shall ensure that each child is accorded the following personal rights: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by:
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Licensee stated on 12/12/2025, Staff 2- S2 was spoken to and personal rights were reviewed with her, which stated children will have extra clothing at all times and no child will be sent outside without inappropriate clothing according to the weather.
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Based on interviews, the licensee did not comply with the section cited above by allowing Child 1- C1 to play outside in inappropriate weather in underwear's, which poses a potential health, safety, or personal rights risk to persons in care.
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In addition, Licensee stated an overview of personal rights and children's supervision shall be reviewed with all staff. Licensee will also review and submit a self-certification letter on section 101223(a)(1)- Personal Rights with all staff's signatures and to submit a copy to CCL by POC due date.

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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.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Liridon Fici
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
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