<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434417071
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:50:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/20/2023 and conducted by Evaluator Melvin S Matos
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230920090621
FACILITY NAME:LUCCIOLA ACADEMYFACILITY NUMBER:
434417071
ADMINISTRATOR:NOPPAKET PONGCHANAFACILITY TYPE:
850
ADDRESS:1711 HAMILTON AVENUETELEPHONE:
(661) 703-7818
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:106CENSUS: 10DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Noppaket PongchanaTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure outdoor playground is free of debris and tripping hazards



INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Mel Matos and Jessica Bongardt met with Noppaket Pongchana, Licensee representative/Director, for a follow up complaint investigation to deliver investigation findings. Based on interviews, observations, and evidence gathered during the investigation process, the Department concludes that the Facility had a broken patio umbrella on the ground area against the fence (located by the back entry/exit door) of the preschool playground that posed a potential tripping hazard to children in care. The broken umbrella patio umbrella was removed from the playground as of 09/27/2023. The allegation noted above is thus found to be SUBSTANTIATED, meaning the allegation is valid because the preponderance of the evidence standard has been met.
A "Type B" deficiency is being cited on the attached LIC 9099-D. Exit interview conducted and report was reviewed with the Licensee representative/Director, Noppaket Pongchana. Appeal rights was also provided to Noppaket prior to conclusion of today's inspection.
Notice of site visit was issued and must remain posted for 30 days
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 07-CC-20230920090621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LUCCIOLA ACADEMY
FACILITY NUMBER: 434417071
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
101238.2(a)(2)
1
2
3
4
5
6
7
Outdoor Space: The surface of the outdoor activity space shall be maintained Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard.
1
2
3
4
5
6
7
The Facility has removed the broken patio umbrella from the playground as of 09/27/2023.

Deficiency is thus cleared.
8
9
10
11
12
13
14
This requirement was not met evidenced by: The Facility had a broken patio umbrella on the ground area against the fence (located by the back entry/exit door) of the preschool playground that posed a potential tripping hazard to children in care. This presents a potential risk to the health, safety, or personal rights of children in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/20/2023 and conducted by Evaluator Melvin S Matos
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230920090621

FACILITY NAME:LUCCIOLA ACADEMYFACILITY NUMBER:
434417071
ADMINISTRATOR:NOPPAKET PONGCHANAFACILITY TYPE:
850
ADDRESS:1711 HAMILTON AVENUETELEPHONE:
(661) 703-7818
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:106CENSUS: 10DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Noppaket PongchanaTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide day care child with first aid.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Mel Matos and Jessica Bongardt met with Noppaket Pongchana, Licensee representative/Director, for a follow up complaint investigation to deliver investigation findings. Based on interviews, observations, record reviews, and evidence gathered during the investigation process, it is concluded that although the allegation noted on this complaint may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is thus UNSUBSTANTIATED.

Exit interview conducted and report was reviewed with the Licensee representative/Director, Noppaket Pongchana. No deficiencies issued. A notice of site visit was given and must remain posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3