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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444412428
Report Date: 10/02/2024
Date Signed: 10/02/2024 02:30:16 PM

Document Has Been Signed on 10/02/2024 02:30 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ACR ACADEMYFACILITY NUMBER:
444412428
ADMINISTRATOR/
DIRECTOR:		JAMES DAWSONFACILITY TYPE:
830
ADDRESS:327 CHURCH STREETTELEPHONE:
(831) 426-3655
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY: 22TOTAL ENROLLED CHILDREN: 18CENSUS: 16DATE:
10/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Naoko DawsonTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mel Matos and Andy Yang met with Naoko Dawson, co-director, for an unannounced case management investigation in response to a self reported Unusual Incident that the Facility reported to the Department on September 25, 2024.

Naoko states that the incident occurred in the Toddler Room on September 25, 2024 at 3:15 PM (during PM snack time). Naoko states that one infant child (C1) brought C1's sippy cup of milk to another infant child (C2) and C2 accidentally touched and possibly took a sip from C1's sippy cup. Naoko states that there were eight infant children and two teachers in the Toddler Room at the time of the incident. Naoko states that one teacher observed the incident and immediately took the sippy cup away from C2. Naoko states that staff had left the children's sippy cups on the children's table in preparation for PM snack, which were accessible to the children, prior to the incident. Naoko states that C2 is allergic to milk and all staff are aware of that. Naoko states that staff noticed C2 developed a rash on C2's face and chest within a few minutes of the incident.

Naoko states that the child's parents had not provided or advised the Facility that C2 required any medication if C2 had an allergic reaction; therefore, staff called C2's mother to advise of the incident. Naoko states that staff reached C2's mother via telephone and the mother advised staff to call 911. Naoko states that 911 was called and the child was transported to a local hospital for observation. Naoko states that the child was not having any sign(s) of distress (difficulty breathing) during the incident. Naoko states that the child was given Benadryl at the hospital and released the same day. Naoko states that the child returned to the Facility the following day and is still enrolled at the Facility. Naoko states that all staff were reminded not to leave children's sippy cups accessible to children prior to handing them out to them and to not allow children to share sippy cups.

Based on the available evidence, it is concluded that one infant child (C2) touched and possibly took a sip from another child's (C1) sippy cup that contained milk on September 25, 2024. Staff had left the children's sippy cups on the children's table in preparation for PM snack, which was accessible to the children, prior to the incident. C2 is allergic to milk and C1 developed a rash as a result of the incident.

This presents a potential health & safety risk and thus a "Type B" deficiency is cited on the attached page (809-D). Exit interview conducted and report was reviewed with the co-director, Naoko Dawson, and copy of appeal rights was provided. A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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 10/02/2024 02:30 PM - It Cannot Be Edited


Created By: Melvin S Matos On 10/02/2024 at 02:01 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: ACR ACADEMY
FACILITY NUMBER: 444412428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
101223(a)(2)

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Personal Rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by: one infant child (C2) touched and possibly took a sip from another child's
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Naoko Dawson, co-director, agreed to submit a Plan of Correction LPA Matos by Friday October 11, 2024 indicating additional procedure(s) that have been/will be implemented to ensure that children are accorded safe, healthful and comfortable accommodations
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(C1) sippy cup that contained milk on September 25, 2024. Staff had left the children's sippy cups on the children's table in preparation for PM snack, which was accessible to the children, prior to the incident.
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at all times, including children with allergies.

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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:Belinda Devall
LICENSING EVALUATOR NAME:Melvin S Matos
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
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