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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416506
Report Date: 08/17/2022
Date Signed: 08/17/2022 03:38:30 PM

Document Has Been Signed on 08/17/2022 03:38 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:BERKMAN, MICHELLEFACILITY NUMBER:
434416506
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 3CENSUS: 3DATE:
08/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Michelle BerkmanTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Mel Matos met with Michelle Berkman, Licensee, for an unannounced case management inspection. Purpose of today's inspection: discuss an unusual incident that the Licensee self reported to the Department.

The Unusual Incident occurred on July 28, 2022 at approximately 12 Noon (lunch time). Licensee states that a 13 month infant child appeared to choke on a small piece of quesadilla that the Licensee had fed to the child as part of the child's lunch. Licensee states that the 13 month old child did not appear to be in distress at the time of the incident, but did appear to be uncomfortable as if something was bothering the child. Licensee states that she assumed that the child was choking on something and thus she proceeded to immediately administer the Heimlich maneuver on the child. Licensee states that the child spit out a small piece of quesadilla after the Licensee performed several back thrusts on the child. Licensee states that the quesadilla pieces were cut into small pieces and of appropriate size for a 1 year old child. Licensee states that the child did not even cry or display any side effects after the incident.

Licensee states that she immediately notified the child's parents via Brightwheel online application that she uses for communication between her and the parents. Licensee states that the parents did not respond back to her and did not come to pick up the child until the child's pick up time later that day. Licensee states that she did not call 911 since the child did not exhibit any symptoms of distress or lack of breathing at the time of the incident. Licensee states that the child did not require any medical attention as a result of the incident and continued with normal activities after the incident.

Licensee states that the child is still enrolled at the Facility (was present during today's inspection) and is doing fine. Licensee states that the child does not have any food allergies/restrictions and she assumes that the incident was "isolated". LPA reviewed the child's file during today's inspection and did not observe any documentation indicating that the child has any food allergies/restrictions.

It is concluded that the incident was an "isolated" one and that the Licensee followed appropriate protocols in response to the incident. No deficiencies issued. Exit interview conducted and report was reviewed with Michelle Berkman, Licensee. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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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