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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434404301
Report Date: 09/07/2022
Date Signed: 09/07/2022 11:18:01 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2022 and conducted by Evaluator Melvin S Matos
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20220630112111
FACILITY NAME:ASSOCIATED STUDENTS CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434404301
ADMINISTRATOR:HEATHER VISEFACILITY TYPE:
850
ADDRESS:460 SOUTH EIGHTH STREETTELEPHONE:
(408) 924-6988
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:72CENSUS: 32DATE:
09/07/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jane ZamoraTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Child sustained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mel Matos met with Jane Zamora, director, for a follow up complaint investigation. Purpose of today investigation: deliver investigation findings.

The investigation of the complaint allegation listed above was conducted by LPA Matos.
Based on interviews, record reviews, observations, and evidence gathered during the investigation process, the Department concludes that a child sustained injuries while in care on June 24, 2022 and the Facility failed to immediately notify the child's parents via telephone of the child's injuries. It is thus concluded that the above allegation is found to be SUBSTANTIATED, meaning the allegation is valid because the preponderance of the evidence standard has been met. A "Type B" deficiency is being cited on the attached LIC 9099-D. A Notice of Site Visit was provided to Jane and must remain posted for 30 days.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 07-CC-20220630112111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ASSOCIATED STUDENTS CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434404301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
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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Director agreed to submit a written Plan of Correction addressing the correct protocol for notifying parents when a child sustains an injury in care. Plan of Correction due by Friday September 23, 2022.
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This requirement was not met as evidenced by: a child sustained injuries while in care on June 24, 2022 and the Facility failed to promptly notify the child's parents via telephone of the child's injuries. This presents a potential risk to the health/safety of children 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.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2