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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710217
Report Date: 08/20/2024
Date Signed: 08/20/2024 11:39:26 AM

Document Has Been Signed on 08/20/2024 11:39 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:CATALYST KIDS - CHERRY CHASEFACILITY NUMBER:
430710217
ADMINISTRATOR/
DIRECTOR:		LINDSAY MASUDAFACILITY TYPE:
840
ADDRESS:1138 HEATHERSTONE WAYTELEPHONE:
(408) 736-0168
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 140TOTAL ENROLLED CHILDREN: 79CENSUS: 0DATE:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:51 AM
MET WITH:LINDSAY MASUDATIME VISIT/
INSPECTION COMPLETED:
11:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mandeep Kaur and Licensing Program Manager(LPM), Belinda Devall, met with Site Director, Lindsay Masuda, for an unannounced case management investigation. Purpose of today's investigation: discuss an incident report that the Facility self reported to the Department. LPA and LPM toured the indoor and outdoor areas of the facility. LPA reviewed one child (C1) file. LPA reviewed four staff (S1,S2,S3 and S4) files for teacher qualifications.

Site Director states that the incident occurred on August 8, 2024 during carnival around 04:12PM. Site Director states that four teachers (S1,S2,S3 and S4)) were present with 34 children on August 8, 2024. Site Director states that Teacher (S3) asked teacher (S2) to take child (C1) to bathroom. Later on, teacher (S3) asked teacher (S2) about the child (C1) where he was. Site Director states that teacher (S2) responded as child (C1) being in the playarea next to Room 1 and Room 2 building. At that moment, teachers (S2 and S3) realized that Child (C1) is not in the playarea next to Room 1 and Room 2 building. Teachers (S2 & S3) notified the Site Director. Site Director states that Site Director started doing head count. During head count, teachers (S2 and S3) and Site Director realized that Child (C2) is missing. Site Director states that children (S1 and S2) were found in playground area together. Site Director states that it might have happened for about 2-3 minutes of time period where children(C1 and C2) were without supervision. Site Director states that teacher (S2) mentioned that the Child (C1) never went to the bathroom and end up staying in the play area next to Room 1 and Room 2 building.

Site director stated that in person training on supervision and watched licensing videos on supervision on August 12 and August 13 2024. Site director states that Regional Director, Kathy Abady provided coaching and training on zoning of the school area on August 16, 2024. Copies of training materials will be emailed to LPA Kaur as Regional Director has the original document.

**Continue on 809-C**
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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: CATALYST KIDS - CHERRY CHASE
FACILITY NUMBER: 430710217
VISIT DATE: 08/20/2024
NARRATIVE
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**Continuation from 809**

As a result of this investigation, LPA and LPM conclude that there was a lack of supervision for the children (C1 and C2) as self-admitted by Site Director. Therefore, one "Type A deficiency is issued today on the attached 809-D. Exit interview conducted and report was reviewed with Site Director, Lindsay Masuda and copy of appeal rights was provided. A notice of site visit has been issued and must remain posted for 30 days.

LPA informed Site Director that this report dated 08/20/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Assembly bill 633 was provided and discussed with Site Director. LPA informed the Site Director to provide a copy of this licensing report dated 08/20/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224), must be placed in the child's file for verification.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
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Document Has Been Signed on 08/20/2024 11:39 AM - It Cannot Be Edited


Created By: Mandeep Kaur On 08/20/2024 at 11:03 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: CATALYST KIDS - CHERRY CHASE
FACILITY NUMBER: 430710217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision: (a)The licensee shall provide care and supervision as necessary to meet the children's needs.(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 observation.
This requirement was not met as evidenced by:
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Site Director stated that she is going to submit the written plan of the supervision of children during special events and during the regular school time with the attendance sheet of attendies regarding the training that was provided on supervision and zoning of the school that was provided on August 12,2024 August 13, 2024 and August 16, 2024 by August 21, 2024.
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Based on interviews and self reported incident report, children(C1 and C2) were found in playarea without supervision on August 08, 2024. This poses an immediate risk to the health, safety and
personal rights of children in care.
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Random samples of A signed acknowledgement of Receipt of Licensing Report (LIC9224) by the currently enrolled parents, will be submitted to department by 08/21/2024.

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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:Belinda Devall
LICENSING EVALUATOR NAME:Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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