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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415566
Report Date: 09/23/2021
Date Signed: 09/23/2021 04:12:09 PM

Document Has Been Signed on 09/23/2021 04:12 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:PATRICE KELLEYFACILITY TYPE:
850
ADDRESS:1835 CUNNINGHAM AVENUETELEPHONE:
(408) 928-5260
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 44TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
09/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Patrice KelleyTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Janette Cruz met with Patrice Kelly, Director and conducted an unannounced follow-up case management inspection today to deliver an amended report dated 09/15/21 regarding an Unusual Incident that the facility self-reported to the Department.

Licensee was issued a Type A deficiency from an incident that occurred at the
day care on 09/01/21 where a child was left on the playground unattended for approximately five minutes.

Facility Program Director Melissa Leza, submitted a written plan of correction on 9/16/21 indicating plans of action to ensure proper supervision of children at all times. Plans of action in the POC include: Training of staff regarding Staffing Matrix, Daily Attendance and Health inspection roster policy and Effective Communications.

LPA observed LIC 9224 Acknowledgement of Receipt of Licensing Reports regarding Type A deficiency, signed by parents in each child's file. LPA also observed an updated Staffing Matrix documenting children's headcount every 30 minutes.

LPA issued a POC clearance to clear the Type A deficiency during today visit.

An exit interview was conducted with Director, Patrice Kelly. No other deficiencies issued during today's inspection.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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