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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201947
Report Date: 04/20/2023
Date Signed: 04/20/2023 04:06:38 PM

Document Has Been Signed on 04/20/2023 04:06 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: 73DATE:
04/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mary Jane BanagaTIME COMPLETED:
11:53 AM
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Licensing Program Analysts (LPAs) Steve Chang and Trang Pham conducted an unannounced case management visit and met with Operation Manager (OM) Mary Jane Banaga.

Today's visit continued on the case management visit conducted on 04/07/2023. The Department received an incident report on 4/1/2023 where the facility reported that inappropriate body touches between 2 clients occurred at the facility.

On 4/7/2023, the Department conducted a physical visit. 3 staff and 2 clients were interviewed. Clients' (R1, R2) documents were obtained.

On 4/10/2023, the Department received an email from OM with a Termination Service Letter for a client dated 4/5/2023, and Actions Taken List dated 4/3/23, 4/4/23, 4/5/23, 4/6/23 and 4/10/23.

During today's visit, LPAs interviewed OM and 2 staff (S1, S2). Staff training documents were obtained.

Exit interview was conducted with OM, The report was provided to OM for signature. A copy of the report was provided to OM.


SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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