434415566-9-23-2021-07-CC-JCRZ-C6VUM5-20210915154147

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415566
Report Date: 09/15/2021
Date Signed: 09/23/2021 04:05:11 PM

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:	SJB-W.C. OVERFELT CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	434415566
ADMINISTRATOR:	PATRICE KELLEY		FACILITY TYPE:	850
ADDRESS:	1835 CUNNINGHAM AVENUE		TELEPHONE:	(408) 928-5260
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	44	CENSUS: 16	DATE:	09/15/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:14 PM
MET WITH:	Patrice Kelley and Melissa Leza		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Janette Cruz, met with Patrice Kelly, Director and Melissa Leza, Program Director for an unannounced case management inspection in response to a self-reported Unusual Incident that the Facility reported to the Department. The Unusual Incident occurred on 09/01/2021 when a preschool child was left unattended in the fenced preschool playground for about 3 to 5 minutes. Patrice states that there were 19 full-time preschool children (6 young preschool and 13 preschool) with two teachers and a teacher aid at the playground after lunch period scheduled from 11:30 AM to 12:30 PM on 09/01/21. Patrice states that preschool kids stayed in the playground after they finish lunch and right before they transition to nap time from 1PM to 3PM. Patrice states that a teacher from WC Overfelt High School informed the preschool teacher, S1, that one child was left behind the fenced playground at around 12:45PM. LPA conducted additional staff interviews of the two teachers and one teacher aid who were present during the incident. Patrice states that child told staff that he was hiding in the playground but child could not specify exact location of where he hid and thus was unaccounted for when the other preschool children came back inside the classroom. Patrice states that they use their staffng matrix form to check for children's headcount. Patrice and Melissa state that the master teacher/teacher is the designated staff to complete headcount using the staffing matrix. LPA obtained a copy of staffing matrix for the week covering the day of incident. Melissa states that staff failed to update the "staffing matrix form" on time of incident to reflect the accurate count of preschool children coming inside classroom from the playground. Melissa states that it was also because of lack of communication why one preschool child was left unaccounted for. Patrice states that the preschool child was unharmed and doing fine. Patrice states that teacher, S2, notified the child's parents on 9/2/21. Patrice states that she notified Regional Director, Rebecca Larsen and advised her of the incident. Program Director, Melissa Leza was notified by Larsen on 9/2/21. Melissa states a staff training about the incident was conducted on 9/9/21 and reminded them of the supervision requirements and accurate head counts. Melissa also states that staffing schedules were adjusted to accommodate classroom ratio and support. LPA obtained adjusted staffing schedule and staff training document conducted on 9/9/21. Melissa states that coaching and disciplinary action of staff involved in incident will be completed by SJB leadership.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SJB-W.C. OVERFELT CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 434415566
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/15/2021 Section Cited	1 2 3 4 5 6 7	101229 (a)(1)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 was not met as evidenced by:
	8 9 10 11 12 13 14	Based on observation, interviews and record reviews, a preschool child was left unattended in the preschool playground for approximately 5 minutes on 09/01/21. This poses an immediate threat to health and safety of children in care.	8 9 10 11 12 13 14	According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months and copy of signed acknowledgement form must be kept in each child's file. LPA advised Licensee that an Office Meeting will be scheduled at a later date. Written notification of the office meeting will be sent to Licensee via mail.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SJB-W.C. OVERFELT CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 434415566
	VISIT DATE: 09/15/2021

NARRATIVE

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Based on the available information, LPA concludes that a preschool child was left unattended due to lack of supervision and therefore a "Type A" deficiency is noted on the attached page (809-D). Civil penalty was assessed and issued to the facility today for violation of Section 101229(a)(1) Care and Supervision.

LPA discussed the requirements of AB633 to Licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Licensee understands the requirements. Upon receipt, Licensee shall post and provide copies of this licensing report 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.

A notice of site visit was issued and posted near the facility entrance along with the Type "A" citation and both notices must remain posted for 30 consecutive days. The Licensee must provide copies of this report to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility during the next 12 months.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC809 (FAS) - (06/04)

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