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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274408906
Report Date: 09/19/2024
Date Signed: 09/19/2024 04:16:37 PM


Document Has Been Signed on 09/19/2024 04:16 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:PEGASUS MONTESSORI SCHOOLFACILITY NUMBER:
274408906
ADMINISTRATOR:ORALIA DIAZFACILITY TYPE:
850
ADDRESS:305 REINDOLLAR AVENUETELEPHONE:
(831) 883-1216
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY:30CENSUS: DATE:
09/19/2024
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Oralia DiazTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Cortez conducted an unannounced Required - 1 Year Inspection. The purpose of today’s visit is to ensure the facility is in compliance with Title 22 California Code of Regulations. LPA met with the Licensee/ Director Oralia Diaz and explained the nature of today's inspection. LPA toured the Facility both inside and outside during todays visit. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), and Activity Schedule. The hours of operation are Monday - Friday, 7:30am - 5:30pm.

LPA reviewed 10 children's and 4 staff files during today's visit. Each child's file reviewed contains the Information and Emergency Information form (LIC 700), immunization records, physicians report, personal rights, and parents rights. All staff files contain the required transcripts/verification of experience. All staff's CPR and First Aid certifications are current. The Director understands that there shall be at least one person with valid CPR and First Aid certifications on site at all times, or present during off-site activities (field trips).

Director understands the conditions, limitations, and capacity specifications of the Facility license. Director understands that children shall be visually supervised at all times. LPA observed that all rooms are in order. Drinking water is readily available for the children in each room and in the outdoor playground area via water dispenser, cups, and water bottles. LPA observed solid waste containers with tight-fitting lids in each room. Staff and children's bathrooms are clean, sanitary. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Director states that there are no weapons or firearms on the premises.

SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Andrea CortezTELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: PEGASUS MONTESSORI SCHOOL
FACILITY NUMBER: 274408906
VISIT DATE: 09/19/2024
NARRATIVE
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LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by children is surrounded by appropriate fencing. LPA observed that the outdoor equipment is age appropriate. LPA did not observe any bodies of water.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. Cleaning supplies are securely stored and inaccessible to the children. LPA observed a fully charged 2A10BC fire extinguisher, and working smoke/carbon monoxide detectors. Director states that the Facility does not administer medications at this time.


The Director Oralia Diaz was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA verified that the lead testing was not completed in accordance to the Written Directives outlined in PIN 21-21.1.CCP. Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). .


Deficiencies cited, see 809-D exit interview conducted and report was reviewed with the Licensee/ Director Oralia Diaz.

SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Andrea CortezTELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/19/2024 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: PEGASUS MONTESSORI SCHOOL
FACILITY NUMBER: 274408906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
WD
101700(b)
Written Directives for Lead Testing
(b) All licensed Child Care Centers operating in buildings constructed before January 1, 2010, shall test their water for lead pursuant to these written directives.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee has not tested their water for lead pursuant to these written directives. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee to submit a written statement ensuring compliance to WD 101700(b). Please send Plan of Correction (POC) to LPA by 10/21/24
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Fire drill was not documented. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee to submit a written statement ensuring compliance to CCR 101174(d)(2). Please send Plan of Correction (POC) to LPA by 9/27/24
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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Andrea CortezTELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 09/19/2024 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: PEGASUS MONTESSORI SCHOOL
FACILITY NUMBER: 274408906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101223(a)(2)
(a) The licensee shall ensure that each child is accorded the following personal rights:

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section. Director is changing children's diapers on the bathroom floor using an unpatted vinyl linning. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee to submit a written statement ensuring compliance to CCR 101223(a)(2). Please send Plan of Correction (POC) to LPA by 9/27/2024.
Type B
Section Cited
CCR
101238(c)
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Outdoor and indoor passageways shall be kept free of obstruction. Outside fance was chained closed and locked and indoor exit was blocked with bookshelf. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee to submit a written statement ensuring compliance to CCR 101238(c). Please send Plan of Correction (POC) to LPA by 9/27/2024
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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Andrea CortezTELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 09/19/2024 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: PEGASUS MONTESSORI SCHOOL
FACILITY NUMBER: 274408906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101173(a)(b)(8)
(a) Each licensee shall have and keep on file a current written, definitive plan of operation. A copy of the plan shall be submitted to the Department with the license application. (8) Sample menus and a schedule for one calendar week indicating the time of day that meals and snacks are to be served.
(b) The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Director stated they do not offer lunches nor snacks as part of their care for the children. Which poses posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee to submit a written statement ensuring compliance to CCR 101173(a)(b)(8). Please send Plan of Correction (POC) to LPA by 10/21/2024

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Andrea CortezTELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5