<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710473
Report Date: 11/16/2022
Date Signed: 11/16/2022 12:10:17 PM


Document Has Been Signed on 11/16/2022 12:10 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:RAINBOW MONTESSORI CHILD DEVELOPMENT CENTERFACILITY NUMBER:
430710473
ADMINISTRATOR:JULIE LORAFACILITY TYPE:
830
ADDRESS:790 EAST DUANE AVENUETELEPHONE:
(408) 738-3261
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY:70CENSUS: 34DATE:
11/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Julie LoraTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mel Matos met with Julie Lora, Director, for an unannounced case management investigation. Purpose of today's investigation: investigate an Unusual Incident that the Facility self reported to the San Jose Child Care District Office on November 10, 2022.

The Unusual Incident occurred on November 10, 2022 at approximately 2:06 PM in Room B. Director states that there were eight infants and three staff in Room B at the time of the incident. Director states that she went to Room B to allow one teacher to take her afternoon break. Director states that the staff handed over a four month old infant to her. Director states that as she turned to the right to take the infant to the diaper changing table, she tripped on a small wooden train toy that was on the carpeted area of Room B. Director states that she cradled the child in her arms as she fell forward. Director states that she landed on her left knee as a result of the fall. Director states that the child rolled out of her arms onto the carpeted floor when she landed on her left knee. Director states that the child's fall was approximately 2-3 inches.

Director states that the child was crying "hard" as a result of the fall. Director states that another staff picked up the child and took the child to the changing table. Director states that the staff was checking the child for any injury(ies) when the child momentarily lost consciousness (few seconds). Director states that the child was breathing and had a heart rate while momentarily unconscious. Director states that 911 and the child's parents were immediately called. Director states that the paramedics were on site within minutes and transported the child to Kaiser Hospital in Santa Clara, CA for observation. Director states that the child was released from the hospital the same day and states that the child did not sustain any injury(ies) as a result of the incident. Director states that the paramedics indicated that the child's crying possibly triggered the child loosing consciousness for a few seconds.

Director states that the child returned to the Facility on Monday November 14, 2022 and is doing fine. LPA toured Room B with Julie during today's investigation and observed that the room is safe for staff and children. Director states that she has reminded staff to ensure that there are no toys lying around in areas of heavy foot traffic in the classrooms.

Exit interview conducted and report was reviewed with Julie Lora, Director. No deficiencies issued during today's investigation. A notice of site visit was given and must remain posted adjacent to the main door for 30 days
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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 1