Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703758
Report Date: 10/13/2016
Date Signed 10/18/2016 09:13:08 AM

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. 300
SAN JOSE, CA 95131
FACILITY NAME:SANTA TERESA CHILDREN'S CENTERFACILITY NUMBER:
430703758
ADMINISTRATOR:JERRIE CALDERONFACILITY TYPE:
850
ADDRESS:6150 SNELL AVENUETELEPHONE:
(408) 928-5270
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:24CENSUS: 15DATE:
10/13/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Debby BarnesTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Berumen met with Program Coordinator Debby Barnes for a follow-up visit regarding an unusual incident received by Licensing on August 15, 2016. Based on information gathered and police report, it was determined that facility staff failed to adequately supervise child(ren) in care, specifically during nap time on or about August 12, 2016 when a un-enrolled minor had inappropriate contact with a child in care.

As a result of this visit, Type A deficiencies cited on the following page:

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2016
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SANTA TERESA CHILDREN'S CENTER
FACILITY NUMBER: 430703758
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2016
Section Cited
101229(a)(1)
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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).

Facility staff failed to adequately supervise child(ren) in care, specifically during nap time on or
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Facility staff was suspended pending this investigation.

Licensee representative must attend a mandatory Noncompliance Conference at the San Jose Regional Office, the
day and time to be determined at a later date.


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about August 12, 2016 when an unenrolled minor had inappropriate contact with a child in care.
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Type A
10/13/2016
Section Cited
101223(a)(2)
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Personal Rights
Each child shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
A child had those rights violated when facility staff allowed an unenrolled minor to be present in the facilty.
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The unenrolled minor responsible for inappropriately touching a child in care is no longer allowed at the facility.

The facility staff will be trained on 100% active supervision, children's personal rights and will review it's program policy regarding visitors.
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This "TYPE A" citation page shall be posted for 30 days. This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB 633.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2016
LIC809 (FAS) - (06/04)
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