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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710441
Report Date: 12/15/2025
Date Signed: 12/15/2025 03:32:44 PM

Document Has Been Signed on 12/15/2025 03:32 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:ROULEAU HEAD STARTFACILITY NUMBER:
430710441
ADMINISTRATOR/
DIRECTOR:		CUC TRANFACILITY TYPE:
850
ADDRESS:1875 MONROVIA DRIVETELEPHONE:
(408) 573-4717
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 65TOTAL ENROLLED CHILDREN: 52CENSUS: 41DATE:
12/15/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Cuc TranTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 12/15/2025, Licensing Program Analyst (LPA) Syeda Bahar conducted an unannounced case management inspection at the facility. LPA met with the Director, Cuc Tran to follow up on an unusual incident that was reported to the San Jose Community Care Licensing Office on 12/3/2025. The incident involved one child (C1) and one staff member (S1). During the inspection, LPA toured the indoor and outdoor areas of the facility. A census was taken.

According to the incident report dated 12/2/2025, at approximately 10:45 AM, children were playing with a frisbee in the outdoor play area. During this time, child (C1) opened the gate and went outside to get the frisbee. Staff member (S2) observed the child (C1) outside and called to staff (S1). Staff (S1) saw the child through the gate and Staff, (S1) was closer to the area and went immediately to get the child (C1) back inside the play area. The child (C1) was doing fine after bringing him back inside the playground.

During today’s inspection, LPA observed that the facility has two gates, a lower gate and a main gate. One gate has a push bar, and the other has a latch. The gates are approximately two feet away from each other. The Director stated that child (C1) opened both gates to get the frisbee.

Based on staff interviews, the center held a meeting and reviewed the center’s supervision policy and protocol with all staff as a follow up action. Staff implemented new supervision policy, including clear communication between staff members, repeating instructions and messages to confirm understating, positioning at least one staff near the blind spots and gates to ensure 100% visual supervision.

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NAME OF LICENSING PROGRAM MANAGER: Mireya Flores
NAME OF LICENSING PROGRAM ANALYST: Syeda Bahar
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2025
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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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: ROULEAU HEAD START
FACILITY NUMBER: 430710441
VISIT DATE: 12/15/2025
NARRATIVE
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[Page 2]

The Director discussed with staff the importance of using the restroom before going outside to ensure the outdoor supervision is not interrupted. Additionally, the Director stated that she spoke with the child’s parents about the incident. The parents are working with their child at home on safety awareness. The Director also shared that staff are working with child (C1) to help him understand the importance of asking for permission and staying safe.

The Director stated that a child safety lock, and a pole will be installed on the first lower outdoor gate to ensure children cannot open the gate. Director stated that the second main gate with the push bar is required for fire safety and cannot be locked. However, a new self-closing hydraulic arm to existing black poly chain link will be installed as safety measure. This will not make the door locked. The door will be unlocked per the fire safety requirement, and accessible by the staff and the parents, from both inside and outside. Director provided LPA with the copy of an estimated cost of the work order for both gates. Director also stated that a visual sign will be posted near the gate to keep the children away from the gates to the outside area from the playground.

During the outdoor inspection, LPA observed there was a tree on the playground. The root of the tree is growing out of the concrete surface causing cracks on the ground. The cracks on the playground surface are a tripping hazard, which is a potential health and safety risk for the children in care during outdoor play time.

Per the California Code of Regulations Title 22, Division 12, Chapter 1, two "Type -B" deficiencies are cited on the attached page LIC 809-D form. Appeal rights were provided.

Exit interview conducted and report was reviewed with the Director, Cuc Tran.

A notice of site visit was given and must remain posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Mireya Flores
NAME OF LICENSING PROGRAM ANALYST: Syeda Bahar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/15/2025 03:32 PM - It Cannot Be Edited


Created By: Syeda Bahar On 12/15/2025 at 03:03 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: ROULEAU HEAD START
FACILITY NUMBER: 430710441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2026
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...Supervision shall include visual observation.
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By the Plan of Correction (POC) due date, 1/15/26, Director will submit the pictures of a child lock, a pole and a self-closing hydraulic arm, installed on the gates in the outdoor playground to the department. Director will submit pictures of visual safety posting in the playground to the department.
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Based on interviews, on 12/2/25, one child (C1) was able to open two gates and went outside alone during outdoor play time. This poses a potential risk to the health and safety of the children in care.
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Type B
01/15/2026
Section Cited
CCR101238.2(d)(2)

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Outdoor Activity Space:(d) The surface of the outdoor activity space shall be maintained: (2) Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard.
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By the Plan of Correction (POC) due date, 01/15/2026, the Director will ensure the playground's concrete surface is free of tripping hazards. The Director will submit pictures of repaired outdoor playground concrete surface, as proof of correction to the department.
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Based on observation and interview, one tree's root is growing out of the concrete surface on the playground, causing cracks on the surface, which a tripping hazard. This 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.
Mireya Flores
NAME OF LICENSING PROGRAM MANAGER:
Syeda Bahar
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


LIC809 (FAS) - (06/04)
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