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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417135
Report Date: 01/14/2025
Date Signed: 01/14/2025 04:58:05 PM

Document Has Been Signed on 01/14/2025 04:58 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: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: 35CENSUS: 24DATE:
01/14/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Stephanie Holson & Matt LindenTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico conducted a Case Management inspection LPA met with Site Director, Stephanie Holson, and Co-Director, Matt Linden. LPA learned from interviews and record review that on August 30, 2024, a child (C1) sustained an injury at the facility and 911 was contacted. Licensee also made structural changes to the facility in August 2024: constructed full wall separating the nap area to the activity area and installed permanent bunk beds for children to nap. Licensee failed to notify Licensing regarding C1's injury and facility's structural changes.

As a result, Type B deficiencies were cited on the following page.

A Notice of Site Visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 01/14/2025 04:58 PM - It Cannot Be Edited


Created By: Marilou Monico On 01/14/2025 at 04:26 PM
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: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2025
Section Cited
CCR
101212(d)(1)(B)

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Reporting Requirements - (d) 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.
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Site Director states that she will submit a written plan and completed Unusual Incident/Injury Report (LIC 624) by 01/17/25 to ensure that Licensing will be notified within the required timeframe for any unusual incidents.
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This requirement was not met as evidenced by: Licensee failed to report to Licensing an injury that occurred on 08/30/24 involving a daycare child (C1) who sustained an injury and 911 was contacted. This posed a potential risk to the health, safety, and personal rights to persons in care.
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Type B
01/17/2025
Section Cited
CCR101212(c)

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Reporting Requirements - (c)The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space. Such structural changes shall include, but not be limited to, room additions.
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Site Director states that she will submit a written plan and updated facility sketch by 01/17/25 to ensure that Licensing will be notified prior to making any future structural changes.
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This requirement was not met as evidenced by: In August 2024, a full wall was constructed separating the nap area to the activity area and installed permanent bunk beds for children to nap, however Licensing was not notified of the structural changes. This posed 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 Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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