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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411588
Report Date: 11/02/2020
Date Signed: 11/02/2020 10:27:21 AM

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:PASITOS SCHOOL, LLCFACILITY NUMBER:
434411588
ADMINISTRATOR:GLORIA LOPEZFACILITY TYPE:
840
ADDRESS:102 SONORA AVENUETELEPHONE:
4083920000
CITY:SAN JOSESTATE: CAZIP CODE:
95110
CAPACITY:45CENSUS: 22DATE:
11/02/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Gloria LopezTIME COMPLETED:
10:20 AM
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LPA Pete Hernandez met with Gloria Lopez, Director, for an unannounced Case Management - Incident Inspection. This investigation was conducted remotely via FaceTime due to Covid-19. The purpose of the inspection was related to an Unusual Incident Report, UIR, that was self reported by Gloria Lopez on 10/27/2020. This incident involved C1 whom sustained and injury to their leg after running on the playground and falling.

On 10/28/2020: LPA Hernandez inspected the physical plant. LPA interviewed the Staff, and Mother of the child. LPA also reviewed the incident report.

It was determined that the injury was not reasonably preventable and the open field playground in the area where the child in care fell was free of any obstacles, holes, an uneven surface, or sprinkler heads.

A deficiency is not being cited based on the LPAs observations, interviews conducted, and record reviews in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, An exit interview was conducted with the Director Gloria Lopez. The inspection was done by using Video Conference, this report has been delivered and reviewed by e-mail and verified by "return receipt." in lieu of a physical delivery and signature.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
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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