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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406682
Report Date: 06/04/2024
Date Signed: 06/05/2024 12:56:59 PM

Document Has Been Signed on 06/05/2024 12:56 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:MISSION COLLEGE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434406682
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, YARELIFACILITY TYPE:
830
ADDRESS:3000 MISSION COLLEGE BLVD MS#6TELEPHONE:
(408) 855-5176
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 23TOTAL ENROLLED CHILDREN: 23CENSUS: 6DATE:
06/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Yareli MartinezTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Morales conducted a Case Management Inspection in response to an Unusual Incident that was received by Community Care Licensing(CCL) on 5/21/24. LPA was greeted by Site Director Yareli Martinez and Enrollment Coordinator Tricia Darrell.

The incident occurred on May 21,2024 in the Bluebell Infant Room, involving an infant (C-1) who was given another infant's bottle by staff. Director stated that the bottles/cups are labeled with a color coded system.

Staff stated that C-1's authorized representative was notified and informed the staff that C-1 has been given the same formula before.

LPA toured the facility, interviewed staff, and obtained supporting documentation.

As a result of this investigation, a Type B deficiency was cited on the following page, LIC809 D.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.

Exit Interview was conducted with the Director and APPEALS RIGHT were given.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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 06/05/2024 12:57 PM - It Cannot Be Edited


Created By: Anna Morales On 06/04/2024 at 01:29 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: MISSION COLLEGE CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434406682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2024
Section Cited
CCR
101223(a)(2)

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Personal Rights:101223(a)(2):
a)The licensee shall ensure that each child is accorded the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations,
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This deficiency has been cleared. Director stated that on May 24,24, an all staff meeting was conducted addressing the importance of double checking to ensure the materials being used belongs to the specific infant. Documentation was obtained during inspection.
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furnishings and equipment to meet his/her needs. This requirment was not evident by: On 5/21/24, an Infant (C1) was given another infant's bottle by staff which poses a potential risk to the health, safety or personal rights 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:Gladys Kuizon
LICENSING EVALUATOR NAME:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
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