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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406682
Report Date: 10/22/2024
Date Signed: 10/22/2024 03:31:44 PM

Document Has Been Signed on 10/22/2024 03:31 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
CCLD Regional Office, 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: 19CENSUS: 16DATE:
10/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:57 PM
MET WITH:Yareli Martinez & Tricia DarrellTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico conducted a Case Management inspection regarding an incident that was reported by the facility to Licensing. LPA met with Site Manager, Yareli Martinez, and Program Specialist, Tricia Darrell. LPA toured the facility, conducted observation, reviewed records, and interviewed staff. LPA obtained a copy of Unusual Incident/Injury Report (LIC 624).

Based on available information, on October 17, 2024 during morning snack, two children (C1 & C2) requiring milk substitutions were inadvertently served the incorrect milk.

As a result of this inspection, Type A deficiency was cited on the following page.

Assembly Bill (AB) 633 was provided and discussed with Program Specialist. LPA informed Program Specialist to provide a copy of this licensing report dated October 22, 2024 that documents a Type A citation to parents/guardians of all children currently enrolled no later than the next business day or the next day the children are in care, and to parents/guardians of any newly enrolled children for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224) must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with Program Specialist, Tricia Darrell.

A Notice of Site Visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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 10/22/2024 03:31 PM - It Cannot Be Edited


Created By: Marilou Monico On 10/22/2024 at 02:51 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: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
101229(a)(2)

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Personal Rights - (a) The licensee shall ensure that each child is accorded the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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 By POC due date: 10/23/24, Tricia to submit a detailed plan to ensure that staff are aware and follow the children's dietary restrictions. Tricia stated that an All Staff Meeting will be conducted on 10/28/24. Training agenda and attendance sheet to be sent to Licensing by 10/29/24.
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This requirement was not met as evidenced by: On 10/17/24, two children (C1 & C2) requiring milk substitutions were inadvertently served the incorrect milk. This posed an immediate risk to the health, safety, and personal rights to 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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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