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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710434
Report Date: 11/22/2024
Date Signed: 11/22/2024 02:35:48 PM

Document Has Been Signed on 11/22/2024 02:35 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:GEORGE MAYNE STATE PS/CHILDREN CTRFACILITY NUMBER:
430710434
ADMINISTRATOR/
DIRECTOR:		MARIA DE LA TORREFACILITY TYPE:
850
ADDRESS:5030 N FIRST ST.TELEPHONE:
(408) 423-1717
CITY:ALVISOSTATE: CAZIP CODE:
95002
CAPACITY: 64TOTAL ENROLLED CHILDREN: 64CENSUS: 15DATE:
11/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Director Maria De La TorreTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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On 11/22/2024 at 1 pm, Licensing Program Analyst (LPA) Manel Estoesta conducted a Case Management Visit. LPA met with the Director Maria De La Torre and explained the nature of the visit. Present on the facility were 2 Staff and 13 preschool children. The facility operates from Monday to Friday from 7:30 am to 5:30 pm.

On 11/19/2024 at 9:44 am, the Director reported C1’s injury that happened in the facility via telephone at the Regional Office.

On LPA Estoesta interview, the incident happened on 11/18/2024 at 3:40 pm in Room F3, C1 was on the floor next to the bookshelves on the “Science Corner,” crying, S1 approached C1 and “pulled” and “picked” C1’s up, to bring back to the group. C1 did not stop crying and when the Director assessed C1’s arm, it appeared that the left upper arm showed redness pattern on it. C1 pulled away her arm that C1's appeared to be C1’s in pain. C1 was brought to an Emergency Room at 5:23 pm on the same day. C1 had history of nursemaid’s elbow. C1 was brought to another medical provider on 11/19/2024, due to pain on the arm and was diagnosed with left elbow injury.

LPA concluded that S1’s interference C1, resulted to C1’s injury. The Licensee is in violation for the section 101223 Personal Rights (a) other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

LPA Estoesta informed the Director, Maria De La Torre, that this report dated 11/22/2024 included a Type B Citation which can be posted as there is a potential risk to the health, safety, or personal rights of children in care. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the Director, Maria De La Torre.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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 11/22/2024 02:35 PM - It Cannot Be Edited


Created By: Manel Estoesta On 11/22/2024 at 02:12 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GEORGE MAYNE STATE PS/CHILDREN CTR
FACILITY NUMBER: 430710434

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited
CCR
101223(a)(3)

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101223 (a)(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning......

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The Director will conduct a Staff Meeting that will focus on Personal Rights on 12/2/2024 and will submit a POC proof to the Regional Office.
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This requirement is not met as evidenced by, based on the LPA's interview, the incident happened on 11/18/2024 at 3:40 pm in Room F3, C1 was on the floor next to the bookshelves on the “Science Corner,” crying, S1 approached C1 and “pulled” and “picked” C1’s up to bring back to the group. C1 did not stop crying and when the Director assessed C1’s arm, it appeared that the left upper arm showed redness pattern on it. C1 pulled away her arm that appeared to be C1’s in pain. C1 was brought to an Emergency Room at 5:23 pm on the same day. C1 had history of nursemaid’s elbow. C1 was brought to another medical provider on 11/19/2024, due to pain on the arm and was diagnosed left elbow injury. LPA concluded that S1’s interference that resulted C1’s injury. This poses a potential risk to the health, safety or personal rights to children in care.
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LPA Estoesta recommended to include the
Children’s Personal Rights in Child Care video
https://ccld.childcarevideos.org/family-child-care-providers/childrens-personal-rights-in-child-care/, for the Staff Meeting.


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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:Jason Jang
LICENSING EVALUATOR NAME:Manel Estoesta
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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