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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201947
Report Date: 04/07/2023
Date Signed: 04/07/2023 04:24:22 PM

Document Has Been Signed on 04/07/2023 04:24 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. 350
SAN JOSE, CA 95131
FACILITY NAME:MULTIPLE INTELLIGENCE TRAINING CENTERFACILITY NUMBER:
435201947
ADMINISTRATOR:AURORA MENDOZAFACILITY TYPE:
775
ADDRESS:3737 MADELINE DRIVETELEPHONE:
(408) 254-9241
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 90CENSUS: 87DATE:
04/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ian GanancialTIME COMPLETED:
11:45 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 Analysts (LPAs) Steve Chang and Trang Pham conducted an unannounced case management visit and met with Staffing Coordinator Ian Gananical ((IG).

LPAs address the purpose of today's visit to IG. The Department received an Incident Report for an incident which occurred on 4/1/2023 where facility reported that a inappropriate body touch between 2 clients occurred at the facility.

LPAs interviewed IG, 2 staff (S1 - S2), and 2 clients (C1 -C2)

LPAs obtained 2 clients's physician reports, and Appraisal Needs and Service Plans.

IG stated the facility will submit an action plan to prevent the similar incident to happen within one week.

Exit interview was conducted with IG, The report was provided to IG for signature. A copy of the report was provide to IG.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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 1