Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430701596
Report Date: 09/13/2017
Date Signed 09/13/2017 10:55:42 AM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2017 and conducted by Evaluator Pam Burkett
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20170908150201
FACILITY NAME:CAMPBELL PARENTS PARTICIPATION PRESCHOOLFACILITY NUMBER:
430701596
ADMINISTRATOR:MONICA GRODINFACILITY TYPE:
850
ADDRESS:528 HARRISON STREETTELEPHONE:
(408) 866-7223
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:26CENSUS: 17DATE:
09/13/2017
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sherrie MalesonTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Lack os Supervision - Facility staff is not ensuring adequate supervision is provided to the children
INVESTIGATION FINDINGS:
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LPA Pam Burkett met with Director, Sherrie Maleson and explained the nature of today's inspection. There were 17 day care children present during this inspection with 1 fully qualified teacher and seven working parents.

Through investigation it was learned that on Friday 9/8/17 four children were left alone in the book room without any staff or parent supervision. It is also possible that children were not supervised in the dramatic play room when other children were taken to the bathroom. Both rooms were toured as well as the playground.

Based on the LPAs observations and interview which was conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Type A deficiency is cited today. Appeal rights were provided. Exit interview was conducted.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Pam BurkettTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 07-CC-20170908150201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CAMPBELL PARENTS PARTICIPATION PRESCHOOL
FACILITY NUMBER: 430701596
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2017
Section Cited
CCR
101212(d)(1)(C)
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Reporting Requirements. Any unusual incident or child absence that threatens the physical or emotional health or safety of a child shall be reported to the Department within 24 hours of the occurrence and in writing within 7 days. Lack of supervision that occurred on 9/8/17 was not reported to CCL
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A written plan of correction must be submitted within 7 days ensuring all incidents will be reported in a timely manner in the future.

Report for the incident that occurred on 9/8/17 will be submitted.
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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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Pam BurkettTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2017
LIC9099 (FAS) - (06/04)
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Control Number 07-CC-20170908150201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CAMPBELL PARENTS PARTICIPATION PRESCHOOL
FACILITY NUMBER: 430701596
VISIT DATE: 09/13/2017
NARRATIVE
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TYPE A DEFICIENCY MUST BE POSTED WITH THE NOTICE OF SITE VISIT FOR 30 DAYS. THE TYPE A DEFICIENCY MUST BE PROVIDED TO ALL PARENTS/GUARDIANS OF ALL CHILDREN IN CARE AND ANY NEW ENROLLED CHILDREN WITHIN THE NEXT 12 MONTHS. THE PARENTS MUST SIGN THE LIC 9224 AND IS MUST BE MAINTAINED IN THE CHILDS FILE.

SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Pam BurkettTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2017
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 07-CC-20170908150201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CAMPBELL PARENTS PARTICIPATION PRESCHOOL
FACILITY NUMBER: 430701596
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2017
Section Cited
CCR
101229(a)(1)
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Care and Supervision. No child shall be left without the supervision, including visual observation, of a teacher at any time Four children were left in the book room without visual supervision.
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The licensee must ensure all children in care are visually observed at all times. A written plan of correction must be submitted within 24 hours.


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Director has changed the job descriptions and emailed all staff and parents regarding supervision. Copies of the email and job descriptions will be submitted to CCL.

This is a Zero Tolerance violation & licensee is being charged a civil penalty in the amount of $150.00.
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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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Pam BurkettTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2017
LIC9099 (FAS) - (06/04)
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