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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410817
Report Date: 05/15/2024
Date Signed: 05/15/2024 11:51:29 AM

Document Has Been Signed on 05/15/2024 11:51 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:NELLY'S CHILDCARE AND PRE-SCHOOLFACILITY NUMBER:
434410817
ADMINISTRATOR/
DIRECTOR:		GREISLYE CARRILLOFACILITY TYPE:
850
ADDRESS:202 RAILWAY AVENUE, BLDG. BTELEPHONE:
(408) 364-1300
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 28DATE:
05/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Greislye CarrilloTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mel Matos met with Greislye Carrillo, director, for an unannounced case management inspection. Purpose of today's investigation: discuss an incident report that the Facility self reported to the Department on May 2, 2024.

Director states that the incident occurred on May 2, 2024 at approximately 5:15 PM during the end of day transition from playground to classroom. Director states that one teacher was in the preschool playground with 8 preschool children. Director states that the parents of 4 preschool children arrived to pick their children while the teacher was transitioning the remaining 4 children back to the PS 1 classroom (located approximately 20 feet from the playground). Director states that one preschool child remained in the preschool playground with the 4 preschool children (being picked up) and their families. The teacher went inside the PS 1 classroom with 3 preschool children.

Director states that the parent of one of the preschool children who was getting picked up went into the PS 1 classroom to notify the teacher and Director that one preschool child had been left in the playground. Director states that she went to the preschool playground and brought the child back to the PS 1 classroom. Director states that the preschool child was never left alone since the parents of the 4 preschool children who were picking up their children were still in the preschool playground. Director states that the entire incident lasted approximately 3 minutes.

Director states that she talked with the child's parent and staff after the incident. Director states that the child's parent was advised that the child was with other parents and children in the playground and was never left alone. Director states that the child is still enrolled at the Facility. Director states that she has talked to staff about transitions and ensuring that the children are accounted for at all times. Director states that she has implemented a "tally board" in the preschool playground where staff are responsible to note the children count when transitioning to and from the playground. Director states that she will also talk to parents re: sign out procedures and not congregating in the preschool playground once their children are signed out.

LPA conclude that there was a lapse of supervision during transition time on May 2, 2024. 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 director, Greislye Carrillo, 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: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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 05/15/2024 11:51 AM - It Cannot Be Edited


Created By: Melvin S Matos On 05/15/2024 at 11:15 AM
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: NELLY'S CHILDCARE AND PRE-SCHOOL
FACILITY NUMBER: 434410817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision: No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Director, Greislye Carrillo, has implemented a "tally board" in the preschool playground where staff are responsible to note the children count when transitioning to and from the playground.
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This requirement was not met as evidenced by: one preschool child was left behind in the preschool playground with 4 other preschool children (being picked up) and their families on 05/02/24. This presents a potential risk to the health, safety or personal rights of children in care.
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Director will submit a written Plan of Correction to LPA Matos by Friday May 24, 2024 indicating additional procedure(s) that have been/will be implemented to ensure that children are supervised at all times.

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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: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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