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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417072
Report Date: 01/26/2024
Date Signed: 01/26/2024 03:14:10 PM


Document Has Been Signed on 01/26/2024 03:14 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: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
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Katrina Owens & Noppaket PongchanaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Marilou Monico, met with Infant Director, Katrina Owens, and Preschool Director, Noppaket Pongchana, for a Case Management Inspection. LPA learned from interviews that an unusual incident that occurred on January 16, 2024 involving a daycare child who sustained burns on the upper arm from a tipped bottle warmer was not reported to Licensing.

As result of this inspection, deficiency was cited on the following page:

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
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.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/26/2024 03:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 B
01/31/2024
Section Cited
CCR
101212(d)(2)

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Reporting Requirements - Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. (1) Events reported shall include the following: (B) Any injury to any child that requires medical treatment.
This requirement was not met as evidenced by:
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By 01/31/24, Katrina and Noppaket stated that they will submit a written Plan of Correction to ensure that unusual incidents shall be reported to Licensing with the required time frame. In addition, a completed Unusual Incident/Injury Report (LIC 624) pertaining to the incident occurred on 01/16/24 be sent to Licensing.
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An unusual incident that occurred on 01/16/24 involving a daycare child who sustained burns on the upper arm from a tipped bottle warmer was not reported to Licensing. This poses a potential risk to the health, safety, and personal rights to 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.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
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
LIC809 (FAS) - (06/04)
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