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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416989
Report Date: 05/09/2023
Date Signed: 06/05/2023 08:57:38 AM

Document Has Been Signed on 06/05/2023 08:57 AM - 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:EMC2 KIDS ACADEMYFACILITY NUMBER:
434416989
ADMINISTRATOR:BLANCA HERNANDEZFACILITY TYPE:
850
ADDRESS:4953 STEVENS CREEK BOULEVARDTELEPHONE:
(408) 409-5901
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 27TOTAL ENROLLED CHILDREN: 27CENSUS: 12DATE:
05/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Blanca HernandezTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Morales conducted a Case Management Visit and was greeted by Director Blanca Hernandez. The Purpose of the Case management visit is to address two discrepancies discovered during a complaint investigation.

The investigation revealed that the Director: enrolled a child (C1)who will not turn two years old until October 2023, on April 18, 2023. and did not inform parent/authorized representative at pick up on April 19, 2023 that C1 sustained a minor injury while in care.

As a result of this investigation, one TYPE A and one Type B deficiency was cited on the following page, LIC809 D.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.

Exit Interview was conducted with the Director Blanca Hernandez and APPEAL RIGHTS were given.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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 12/29/2025 11:51 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/22/2023 02:06 PM


Created By: Anna Morales On 05/09/2023 at 09:28 AM
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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: EMC2 KIDS ACADEMY
FACILITY NUMBER: 434416989

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2023
Section Cited
CCR
101161(a)

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 Limitations on Capacity:101161(a): A licensee shall not operate a child care center beyond the conditions and limitations specified on the license, including the capacity limitation. This requirement was not met by:
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The Director stated that she will submit a plan to ensure that she operates in accordance with the terms specified in the plan of operation at all times. Director stated that the C1 last day at the preschool was on 4/25/2023.
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Through interview and record review, On 4/18/23, the Director enrolled C1(DOB 10/23) who is younger than two years of age. This poses an immediate risk to the health, safety, and personal rights to children in care.
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According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months & copy of the signed acknowledgment form must be kept in each child's file.
Type B
06/06/2023
Section Cited
CCR101126(a)(2)

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Health-Related Services:101126(a)(2):In the case of less serious injuries including, but not limited to...bites from other children requiring assessment and/or administration of first aid by staff, the licensee shall document the injury in the child's record and notify the child's authorized representative

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Director stated that she will submit a plan to CCL that will ensure that parents/ authorized representative are notified if child(ren) sustain an injury upon pick up by the POC date.
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of the nature of the injury when the child is picked up from the center. This requirement was not met as evidence by: On 4/19/2023, staff did not inform the parent of C1 upon pick up, that C1 sustained an minor injury at day care, which posed a potential health, safety or personal rights risk to C1.
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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