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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400448
Report Date: 07/30/2024
Date Signed: 07/31/2024 08:51:04 AM


Document Has Been Signed on 07/31/2024 08:51 AM - 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:MARTINSON CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434400448
ADMINISTRATOR:ALYSSIA SALAZARFACILITY TYPE:
850
ADDRESS:1350 HOPE DRIVETELEPHONE:
(408) 988-8296
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY:70CENSUS: 36DATE:
07/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:ALyssia SalazarTIME COMPLETED:
05:25 PM
NARRATIVE
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Licensing Program Analyst conducted a Case Management investigation, and was greeted by Director Alyssia Salazar. LPA observed 18 children inside the Bumblee Classroom and 18 children inside the Butterfly classroom. LPA observed that the facility was observed to be in compliance with teacher to child ratio requirement during visit.

During the course of this investigation, LPA was unable to review one of the Staff's file (S1) including evidence of immunization's (TDAP, MMR and Influenza or decline statement),and TB test. Based on interviews conducted with Staff (S1), S1 began to work for Martinson Child Development Center on July 1, 2024.

LPA informed Director Alyssia Salazaar that Two Type B deficiencies are being cited. LPA discussed the deficiencies and Plan of Correction's(POC's) during the exit interview. APPEAL RIGHTS were given.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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 2


Document Has Been Signed on 07/31/2024 08:51 AM - It Cannot Be Edited

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: MARTINSON CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434400448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
HSC
1596.7995(a)(1)

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1596.7995 (a)(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
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Director stated that she will submit proof of immunizations for S1, by the POC date.
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Based on interview(s) the Director did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. S1 is missing proof of immunizations for measles and pertussis and influenza (or statement of decline)
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Type B
08/16/2024
Section Cited
CCR101217(a)

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101217 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
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Director stated that she will submit a plan to ensure that all staff will have personnel records on file. Director will also send a copy of S1's TB test. The plan and copy of the TB test will be submitted by the POC date.
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Based on interview(s), the Director did not comply with the section above which poses a potential health,safety or personal rights to persons in care.S1 does not have a personnel record on file.
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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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2