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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415557
Report Date: 03/28/2023
Date Signed: 04/06/2023 10:25:50 AM

Document Has Been Signed on 04/06/2023 10:25 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:FOOTHILL HEAD STARTFACILITY NUMBER:
434415557
ADMINISTRATOR:RENEE GARCIAFACILITY TYPE:
850
ADDRESS:2750 RIVERRUN DRIVETELEPHONE:
(408) 392-3891
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 23DATE:
03/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Emma MonicaTIME COMPLETED:
03:49 PM
NARRATIVE
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On 3/28/2023 LPAs Pete Hernandez and Jovani Dillon made an unannounced Case Management - Incident Visit to the facility in response to an incident that occurred on 3/23/2023. LPA's met with Preschool Supervisor Emma Monica and explained the purpose of the visit. LPAs toured the facility and interviewed staff, LPA learned that on March 23,2023 at approximately:10:40AM a preschool child had wandered out of the classroom entrance and walked out of the classroom unnoticed in to the courtyard. Another child notified the staff that Child (C1) was outside. A Staff immediately recovered the child (C1) who was standing outside of the classroom entrance.

LPA inspected the physical plant. LPA interviewed staff. LPA also reviewed incident report and collected a copy of the childrens roster.

There is an issuance of Type A citations today, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is being cited based on the LPAs observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D, An exit interview was conducted, and Plan of Corrections were reviewed and developed with the licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Roopali i Born, 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: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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 04/06/2023 10:27 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/05/2023 02:40 PM


Created By: Pietro Hernandez On 03/28/2023 at 02:52 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: FOOTHILL HEAD START
FACILITY NUMBER: 434415557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2023
Section Cited
CCR
101229(a)(1)

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Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). This requirement is not met as evidenced by:
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By POC date: Program Director states they will submit a detailed plan to ensure that children are supervised at all times. Per CCR 101197, a civil penalty is not being assessed.
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LPA's observation, interviews conducted, and record review during the investigation it was determined that the 6 staff had not noticed the infant leaving the classroom through the front entry, only to be notified by another child that (C1) was outside of the classroom in the courtyard. This poses an immediate risk to the health and safety of the children in care.
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Upon receipt, licensee shall post and provide copies of this licensing report,have LIC 9224 signed and kept on file, to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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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:Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023


LIC809 (FAS) - (06/04)
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