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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415566
Report Date: 09/22/2023
Date Signed: 09/22/2023 01:17:55 PM

Document Has Been Signed on 09/22/2023 01:17 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:SJB-W.C. OVERFELT CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434415566
ADMINISTRATOR:YESENIA RIVAS BEJARANOFACILITY TYPE:
850
ADDRESS:1835 CUNNINGHAM AVENUETELEPHONE:
(408) 928-5260
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 44TOTAL ENROLLED CHILDREN: 44CENSUS: 6DATE:
09/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Reema SainiTIME COMPLETED:
01:25 PM
NARRATIVE
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On 09/22/2023 at 12:50 PM, Licensing Program Analyst (LPA) Susy Cervantes, met with director, Reena Saini, for a case management visit due to an incident. Present were 6 children with two teachers and director.

Incident occurred in August where a child got injured while in care and the facility staff failed to report the incident to parents and the department. LPA observed there were no incident reports made for the child.

Type B deficiency cited during today's visit. Exit interview conducted and report was reviewed with the director, Reena Saini. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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 10/12/2023 01:12 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/11/2023 08:03 AM


Created By: Teodoro Trujillo On 09/22/2023 at 01:04 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
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: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/06/2023
Section Cited
CCR
101226.3(b)

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Observation of the Child

Any unusual behavior, any injury or signs of illness requiring assessment and/or administration of first aid by staff shall be reported to the child's authorized representative and recorded in the child's record.
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Director and staff will review regulation 101226.3(b) and will submit a letter stating their understanding of the regulation and what they plan to do to prevent this from happening again by close of business on October 06, 2023.
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This requirement ws not met as evidenced by: Based on record review and interviews, facility staff failed to inform parents of an injury that a child sustained while in care. This poses a potential risk to the health, safety, and personal rights of the children in care.
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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:Susy Cervantes
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
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