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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434417072
Report Date: 01/26/2024
Date Signed: 01/26/2024 03:09:29 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
01/22/2024 and conducted by Evaluator Marilou Monico
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240122123354
FACILITY NAME:LUCCIOLA ACADEMYFACILITY NUMBER:
434417072
ADMINISTRATOR:ANNA KATRINA OWENSFACILITY TYPE:
830
ADDRESS:1711 HAMILTON AVENUETELEPHONE:
(408) 300-1646
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:24CENSUS: 6DATE:
01/26/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Katrina Owens & Noppaket PongchanaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Due to negligence, a day care child sustained multiple injuries while in care.
Staff did not ensure that a bottle warming device was not within reach of a day care child.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Marilou Monico, met with Infant Director, Katrina Owens, and Preschool Director, Noppaket Pongchana, for a Complaint Inspection.

During today's inspection, LPA toured the facility, conducted staff interviews as well as obtained children's roster and other pertinent documents.

During the investigation process, it was found that due to neglect/lack of supervision, a daycare child sustained multiple injuries while in care. A daycare child was also able to reach a bottle warming device that was placed at the edge of the counter table. The child sustained burns on the upper arm from the tipped bottle warmer. Based on the information gathered from interviews and documents obtained, the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED.

California Code of Regulations (Title 22, Division 12) are being cited on attached LIC9099-D.
A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
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-20240122123354
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: 434417072
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2024
Section Cited
CCR
101229(a)(1)
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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs.

This requirement was not met as evidenced by:
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By 01/29/24, Katrina and Noppaket indicated that they will submit a written Plan of Correction to Licensing and will conduct an all staff training including areas on supervision, personal rights, safety, first aid, and reporting requirements. Training agenda and proof of attendance to be sent to Licensing after the training.
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Due to neglect/lack of supervision, a child sustained multiple injuries while in care. This poses an immediate risk to the health, safety, and personal rights of children in care.
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Type A
01/29/2024
Section Cited
CCR
101223(a)(2)
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Personal Rights -The licensee shall ensure that each child is accorded the following personal rights: (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement was not met as evidenced by:
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By 01/29/24, Katrina and Noppaket stated that they will submit a written Plan of Correction to ensure that children's personal rights are not violated.
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A daycare child was able to reach a bottle warming device that was placed at the edge of the counter table. The child sustained burns on the upper arm from the tipped bottle warmer. This poses an immediate risk to the health, safety, and personal rights of children in care.
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Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3