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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202124
Report Date: 09/05/2024
Date Signed: 09/05/2024 09:35:56 AM

Document Has Been Signed on 09/05/2024 09:35 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BEYOND POTENTIAL LEARNING CENTERFACILITY NUMBER:
435202124
ADMINISTRATOR/
DIRECTOR:		CARMELA MAGPAYOFACILITY TYPE:
775
ADDRESS:1753 SOUTH MAIN STREETTELEPHONE:
(408) 438-0442
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 75CENSUS: 61DATE:
09/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Program Director Melissa RamosTIME VISIT/
INSPECTION COMPLETED:
09:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter and Marcela Yanez arrived unannounced to deliver the results of a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Program Director (PD) Melissa Ramos

While investigating the complaint 26-AS-20240802161419, LPA's discovered violations during the complaint investigation process. PD stated on July 15, 2024 she was informed by C1's family member that C1 had sustained bruises a week prior. PD stated she did not send an incident report. PD stead the Staff who was supposed to send it, became sick. And the incident Report regarding C1 was not sent.

Based on record review, the facility did not send an incident report regrading client C1.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Program Director Melissa Ramos. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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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Document Has Been Signed on 09/05/2024 10:17 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/05/2024 09:37 AM


Created By: Manuel Monter On 09/05/2024 at 09:10 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BEYOND POTENTIAL LEARNING CENTER
FACILITY NUMBER: 435202124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2024
Section Cited
CCR
82061(a)

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82061 Reporting Requirements (a)Upon the occurrence, ...any of the events specified in Section 82061(a)(1), a report shall be made to the licensing agency ... within seven days following the occurrence of the event.
This requirement was not met as evidenced by;
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ADM stated she will conduct a training regarding Reporting requirement's. ADM stated she will send documentation the training has taken place. ADM stated she will send a letter of understanding regarding the regulation.
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Based on interviews conducted and record reviewed, the facility did not send an incident report to Community Care Licensing regading client C1 sustaining brusing. This poses/posed a potential health, safety or personal rights risk to persons in care.
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*This 809-D page is being amended to add the plan of correction that was not imputed erroneously.

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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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
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