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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415566
Report Date: 02/22/2023
Date Signed: 02/22/2023 02:23:24 PM

Document Has Been Signed on 02/22/2023 02:23 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
SAN JOSE-DAY CARE, 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: 32CENSUS: 17DATE:
02/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Yesenia Rivas-BejaranoTIME COMPLETED:
02:35 PM
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Licensing Program Analysts (LPAs) Mel Matos and Cynthia Tamayo met with Yesenia Rivas-Bejarano, director, for an unannounced case management investigation. Purpose of today's inspection: discuss an Unusual Incident that the Facility self reported to the Department on February 13, 2023 via phone and written report.

Unusual Incident occurred on Friday February 10, 2023 when a preschool child, age 4 years, notified Stephanie Lopez, teacher, that the child's tongue hurt after eating pineapple with her lunch. Yesenia states that the staff inspected the child's tongue and noticed that the child's tongue and lips were red. Yesenia states that the staff also noticed that the child's hands were red and that the child had a rash on the child's chest. Yesenia states that the child was not in distress but states that staff decided to call the child's parents. Parents elected to picked up the child Yesenia states that the child had been enrolled as of January 2, 2023 and states that the Facility was not aware of any food allergies. LPAs reviewed the child's file and did not observe any documents on file noting that the child had any food allergies prior to the incident of February 10, 2023.

Yesenia states that the child's father arrived within 15 minutes to pick up the child from the Facility. Yesenia states that the child's father took the child to Regional Medical Center in San Jose, CA and the child was diagnosed with a food allergy (pineapple). Yesenia states that a health plan for the child was put in place after the incident & diagnosis and states that the child was not allowed to return until the health plan was completed.

LPAs reviewed the child's file and observed the health plan documents, including medication consent on file. Copies of documents were provided to LPAs during today's investigation. Yesenia states that the child is doing fine now and returned to the Facility as of Tuesday February 21, 2023.

Based on the information & evidence obtained for this investigation, it is concluded that the Facility was not aware that a preschool had a food allergy prior to the incident that occurred on February 10, 2023. Exit interview conducted and today's report was reviewed with the director, Yesenia Rivas-Bejerano. Yesenia was advised that no deficiencies issued. Notice of Site visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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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