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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400006
Report Date: 06/13/2024
Date Signed: 06/13/2024 02:52:31 PM

Document Has Been Signed on 06/13/2024 02:52 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:CATALYST KIDS - BISHOPFACILITY NUMBER:
434400006
ADMINISTRATOR/
DIRECTOR:		RUMA CHOKSHIFACILITY TYPE:
840
ADDRESS:450 NORTH SUNNYVALE AVETELEPHONE:
(408) 739-2611
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY: 105TOTAL ENROLLED CHILDREN: 68CENSUS: 32DATE:
06/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Fadila Mahiouz & Alyssa ScholesTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mel Matos met with Fadila Mahiouz, assistant director, and Alyssa Scholes, regional manager, for an unannounced case management investigation. The Facility self reported an Unusual Incident to the Department on June 10, 2024. The Unusual Incident occurred on Friday June 7, 2024.

A school age child from the H1A classroom got hit in the chest while playing soccer outside with his class on Friday June 7, 2024 at approximately 3:30 PM. Alyssa states that there were 14 school age children outside with one teacher in the H1A classroom. The school age child asked for an ice pack after getting hit in the chest and the teacher stated that there were none outside and that he would get one for the child once the class returned to the H1A classroom. The teacher did not give the child an ice pack upon returning to the H1A classroom. Alyssa states that the school age child did not require medical attention as a result of the incident. The child's mother ended up complaining to staff at pick up time and the Facility opened an investigation into the matter.

Alyssa states that the staff person was put on leave as of Monday June 10, 2024 and has not returned to the Facility. Alyssa states that the investigation is in process. Alyssa states that the school age child is doing fine and is still enrolled at the Facility.

Based on the available evidence, it is concluded that a school age child asked for an ice pack after being hit in the chest while playing soccer and was not provided one. The school age child did not require medical attention as a result of the incident.

This presents a potential health & safety risk and thus a "Type B" deficiency is cited on the attached page (809-D). Exit interview conducted and report was reviewed with the regional manager, Alyssa Scholes, and copy of appeal rights was provided. A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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 06/13/2024 02:52 PM - It Cannot Be Edited


Created By: Melvin S Matos On 06/13/2024 at 02:09 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: CATALYST KIDS - BISHOP
FACILITY NUMBER: 434400006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
101223(a)(2)

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Personal Rights: The licensee shall ensure that each child is accorded the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Alyssa Scholes, regional manager, agreed to submit a written Plan of Correction (POC) detailing what steps have been implemented to ensure that the Facility has sufficient furnishings & equipment to meet
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This requirement was not met as evidenced by: a school age child requested and was not provided an ice pack after the child was hit in the chest while playing soccer outside on 06/07/24. This presents a potential risk to the health, safety or personal rights of children in care.
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the needs of all children.

POC due by Friday June 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:Melvin S Matos
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
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