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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417135
Report Date: 03/21/2025
Date Signed: 03/21/2025 10:58:59 AM

Document Has Been Signed on 03/21/2025 10:58 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:TESSELLATIONS CHILDREN'S CENTERFACILITY NUMBER:
434417135
ADMINISTRATOR/
DIRECTOR:		STEPHANIE HOLSONFACILITY TYPE:
850
ADDRESS:1170 YORKSHIRE DRIVETELEPHONE:
(650) 260-4409
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 36TOTAL ENROLLED CHILDREN: 33CENSUS: 0DATE:
03/21/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Matt LindenTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Marilou Monico, met with Co-Director, Matt Linden, for an unannounced Case Management Inspection. Purpose of today's investigation: to investigate an incident report that the Facility self reported to the Department. The incident occurred on March 18, 2025.

During today's investigation, LPA toured the facility, interviewed staff, and reviewed records.

The investigation comprised of interviews, observations, and records review. Based on interviews, S1 was leading the cooking project with some of the children from 12:45 PM to 1:15 PM. C1 was one of the participants. The burner and the hot pot that were used in cooking were on the countertop away from the children. At around 1:15 PM, C1 approached S2 and showed the two fingers of the left hand with blisters. C1 didn't recall how it happened when asked by S2. S2 cleaned the injury with antiseptic wipes, covered the injuries with bandaids, and ice packs to reduce the pain. Staff were unaware how the child sustained the blisters until the child reported to the mother that the child had touched a pot that was being used for a cooking project.

As a result of this investigation, there was lack of supervision when a child sustained an injury and no one among the staff observed how it happened.

Type B deficiency was cited on the following page.

A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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 03/21/2025 10:58 AM - It Cannot Be Edited


Created By: Marilou Monico On 03/21/2025 at 10:30 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: TESSELLATIONS CHILDREN'S CENTER
FACILITY NUMBER: 434417135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2025
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
Responsibility for Providing Care & 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.
1
2
3
4
5
6
7
Co-Director, Matt Linden, stated that he will submit a written plan by 03/24/25 to ensure that the children are provided with adequate supervision at all times and steps to take to prevent this incident from occurring again.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: There was lack of supervision when a child (C1) sustained an injury and no one among the staff observed how it happened.
This poses a potential risk to the health, safety, and personal rights to 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:Gladys Kuizon
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


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