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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411588
Report Date: 08/23/2021
Date Signed: 08/23/2021 01:07:42 PM

Document Has Been Signed on 08/23/2021 01:07 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:PASITOS SCHOOL, LLCFACILITY NUMBER:
434411588
ADMINISTRATOR:GLORIA LOPEZFACILITY TYPE:
840
ADDRESS:102 SONORA AVENUETELEPHONE:
(408) 392-0000
CITY:SAN JOSESTATE: CAZIP CODE:
95110
CAPACITY: 45TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Gloria LopezTIME COMPLETED:
01:15 PM
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LPA Pete Hernandez met with Gloria Lopez, Director, for a subsequent unannounced Case Management - Incident Inspection. The purpose of the inspection is to review an unusual incident report, UIR, that was self reported on 8/4/2021. This incident involved S1, S2 and C1 and a potential lack of supervision on 8/4/2021. There were no injuries resulting from this incident.

LPA inspected the physical plant. LPA interviewed staff, and parents. LPA also reviewed incident report, staff file, and child's file. Based on information acquired throughout the investigation, the LPA has determined that there was NO basis regarding a lack of supervision related to this incident. It appears to be an isolated incident involving the child.

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, A copy of this report was left with the Director Gloria Lopez, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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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