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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434417288
Report Date: 05/08/2024
Date Signed: 05/08/2024 10:58:19 AM

Unsubstantiated


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
03/05/2024 and conducted by Evaluator Samantha Yip
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240305133850
FACILITY NAME:SONG, JISOOFACILITY NUMBER:
434417288
ADMINISTRATOR:SONG, JISOOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 710-6765
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:14CENSUS: 7DATE:
05/08/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jisoo SongTIME COMPLETED:
11:05 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Daycare owner is not residing in the home.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Samantha Yip conducted unannounced complaint investigation. LPA met with Assistant, Kyungju Seo. Licensee Jisoo Song arrived at 10:05AM. LPA explained the reason for the inspection to Licensee.

During the course of this investigation, LPA conducted observation and inspected the physical plant. LPA also interviewed staff and parents. Based on the information obtained, the above allegation is found to be UNSUBSTANTIATED, meaning although, the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted and report was reviewed with Licensee Jisoo Song. A notice of site visit has been issued and must remain posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
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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