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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710539
Report Date: 12/19/2024
Date Signed: 12/19/2024 12:23:19 PM

Document Has Been Signed on 12/19/2024 12:23 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:CHALLENGER SCHOOL-SUNNYVALEFACILITY NUMBER:
430710539
ADMINISTRATOR/
DIRECTOR:		HENRY, JACQUELINEFACILITY TYPE:
850
ADDRESS:1185 HOLLENBECK AVENUETELEPHONE:
(408) 245-7170
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 168TOTAL ENROLLED CHILDREN: 73CENSUS: 52DATE:
12/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Jacqueline HenryTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mandeep Kaur, met with Director, Jacqueline Henry and explained the purpose of the investigation: continuation of the Case Management- Incident investigation, that was self reported on 12/06/2024. LPA conducted incident investigation comprising of interviews, evidence gathered and records review.

During today's investigation, LPA interviewed two (2) staff including Director and a child (C1).

Based on interviews and evidence gathered, director self-admitted that a staff (S1) did not report the incident to anyone in the facility, department concludes that parents/authorized representative of the children (C2 & C3) were not notified regarding the incidents occurred on two separate occasions and a staff(S1) did not provide care and supervision as necessary to meet the children needs. Therefore, one "Type B deficiency is issued today on the attached 809-D and one technical violation is being issued.

Exit interview conducted, report was reviewed with Director, Jacqueline Henry and copy of appeal rights was provided.

A NOTICE OF SITE VISIT HAS BEEN GIVEN AND MUST BE POSTED FOR 30 DAYS.


SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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 12/19/2024 12:23 PM - It Cannot Be Edited


Created By: Mandeep Kaur On 12/19/2024 at 11:34 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: CHALLENGER SCHOOL-SUNNYVALE
FACILITY NUMBER: 430710539

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2025
Section Cited
CCR
101226.3(b)

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Observation of the Child: (b) Any unusual behavior, any injury or signs of illness requiring assessment and/or administration of first aid by staff shall be reported to the child's authorized representative and recorded in the child's record.
This requirement was not met as evidenced by:
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Director agreed to submit the copy of the both incident reports that is going to be reported to the parents/authorized representative of the children (C2 & C3) to the department. Director will submit the copy of the detailed topics of the training provided to their staff regarding Title 22 regulations: Observation of the child regarding unusual behavior and injury of a child reporting to the child's parents/authorized respresentative with the attendance sheet to the department by Plan of correction due date: 01/17/2025.
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Based on interviews and evidence gathered, parents/authorized representative of the children (C2 & C3) were not notified regarding the incidents occurred on two separate occasions: one incident occurred on 12/05/2024 with child (C3). Based on interviews, one incident with child (C2) occurred in November 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: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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