Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404912
Report Date: 10/23/2015
Date Signed 10/23/2015 03:30:43 PM

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:ROSEMARY PRESCHOOLFACILITY NUMBER:
434404912
ADMINISTRATOR:GINA PHIFACILITY TYPE:
850
ADDRESS:401 WEST HAMILTON AVENUETELEPHONE:
(408) 341-7000
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:189CENSUS: DATE:
10/23/2015
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gina PhiTIME COMPLETED:
03:45 PM
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LPA Adeyemi met with center director Gina Phi with regards to an incident report that was received on 10/15/15.
Incident report was sent to CCL to notify CCL, that a child suffered an injury to his pinky finger on his hand.

LPA discussed incident with director.

A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded licensee of the applicable $100.00 civil penalty per person per day up to five days, (a maximum of $500.00 per person) for the first violation within a 12 month period. A civil penalty of up to $1000 per day up to 30 days (a maximum of $3000.00 per person) will be assessed for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children for a second criminal record clearance violation within a 12 month period.


As a result of this visit, the following deficiencies are cited according to Title 22, Division 12, Chapter 3 of the CCR on the following pages:

NOTICE OF SITE VISIT DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY. PROVIDER MUST POST NOTICE WITH ANY TYPE "A" DEFICIENCIES CITED TODAY. NOTICE REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Esther AdeyemiTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2015
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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