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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417071
Report Date: 11/06/2025
Date Signed: 11/06/2025 11:30:47 AM

Document Has Been Signed on 11/06/2025 11:30 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:LUCCIOLA ACADEMYFACILITY NUMBER:
434417071
ADMINISTRATOR/
DIRECTOR:		NOPPAKET PONGCHANAFACILITY TYPE:
850
ADDRESS:1711 HAMILTON AVENUETELEPHONE:
(408) 300-1646
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 104TOTAL ENROLLED CHILDREN: 104CENSUS: 36DATE:
11/06/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:41 AM
MET WITH:Katrina Owens - Facility RepresentativeTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 11/06/2025, Licensing Program Analyst (LPA) Jennifer "Jen" Beehler conducted an unannounced Case Management - Incident Inspection. LPA was greeted by the Director and provided access to the facility. LPA stated the reason for the visit. Upon arrival, LPA toured the inside and outside of the facility and collected the census.

There were 36 preschool children, 12 teachers and two (2) Directors present which is compliant with the ratio and capacity requirements.

During the course of this investigation, it was revealed through witness testimony that during a transition from the play yard to the classroom Child #1 (C1) ran away from the group that consisted of one (1) staff person (S1) and four (4) preschool children. S1 observed C1 running up the hallway and into the Lobby where S1 lost sight of C1. S1 checked the rooms located in the lobby and could not locate C1. At this point, it was determined that C1 had exited the facility without staff present. S1 moved the four (4) preschool children into a nearby classroom (Sequoia) where teachers were available to supervise the children. S1 exited the lobby to search for C1. S1 ran to the street (Hamilton Ave) and did not observe the child. S1 looked back at the facility and located C1 in the parking lot. A second Staff person (S2) arrived to assist at that moment and ran to the child to secure him. S1 and S2 worked together to bring C1 back into the facility.

Due to today's investigation, a deficiency is cited along with a Civil Penalty. More information provided on the attached LIC809-D and LIC421IM.

Continued on Page 2
NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: LUCCIOLA ACADEMY
FACILITY NUMBER: 434417071
VISIT DATE: 11/06/2025
NARRATIVE
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LPA Jennifer Beehler informed Director Noppaket Pongchana that this report dated 11/06/2025 documents one (1) Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Jennifer Beehler informed the Director to provide a copy of this licensing report dated 11/06/2025 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

LPA provided the Director with a copy of the LIC9224 with today's date.

Exit interview conducted with Noppaket Pongchana, Facility Representative. Report was reviewed and provided along with appeal rights to the Facility Representative, Noppaket Pongchana.

NOTICE OF SITE VISIT PROVIDED AND MUST REMAIN POSTED FOR 30 DAYS.
NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2025 11:30 AM - It Cannot Be Edited


Created By: Jennifer Beehler On 11/06/2025 at 10:56 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LUCCIOLA ACADEMY
FACILITY NUMBER: 434417071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2025
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Director creates a written plan and will schedule a date to train staff which will include role playing. Director to provide copy of plan and date of training by POC due date.
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This requirement has not been met as evidenced by: C1 exited the facility without supervision from staff. This poses an immediate risk to the health, safety and personal rights of children in care.
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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.
Deanna Villagrana
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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