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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354413128
Report Date: 12/12/2022
Date Signed: 12/12/2022 01:39:56 PM


Document Has Been Signed on 12/12/2022 01:39 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:ASJUSD/SAN JUAN MI ESCUELITA PRESCHOOLFACILITY NUMBER:
354413128
ADMINISTRATOR:FABIOLA VALADEZFACILITY TYPE:
850
ADDRESS:100 NYLAND DRIVETELEPHONE:
(831) 623-4538
CITY:SAN JUAN BAUTISTASTATE: CAZIP CODE:
95045
CAPACITY:24CENSUS: 12DATE:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Margarita Carrillo-GaitanTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA), Deanna Villagrana, conducted an unannounced required one year inspection to the Facility today. LPA met with director, Margarita Carrillo-Gaitan and explained the nature of today's visit to her. The Facility is located in a classroom at San Juan Elementary in the preschool room. The playground area of the Facility is located behind the classroom. LPA notes that the Facility has two waivers on file which allows them to share the bathroom and playground with the kindergarten class located next door to the preschool. LPA reminded Margarita that the preschool and kindergarten children cannot commingle, either inside the Facility or in the playground area of the Facility, outside the times of the approved waivers.

LPA toured the Facility both inside and outside for today's inspection. 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, Menus, and Activity Schedule.

All staff have clearances through Aromas-San Juan Unified School District. LPA reviewed ten children's and three staff (1 director, 1 teacher and 1 aide) files during today's inspection. Staff 1 and 3 are missing LIC501. Child 8 and 10 are missing a signed Admission Agreement. Child 1 is missing LIC627. Child 4 and 5 are missing TB test results. Child 5 is missing Health History form. Director has current CPR and First Aid certifications on file. Director and one teacher files reviewed contain the required transcripts/verification of experience. Margarita 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). LPA observed teachers have required immunization records on file and Mandated Reporter training certificates.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
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: ASJUSD/SAN JUAN MI ESCUELITA PRESCHOOL
FACILITY NUMBER: 354413128
VISIT DATE: 12/12/2022
NARRATIVE
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LPA observed that the teacher/child ratio was in compliance during today's visit. LPA observed 12 preschool children with one teacher and one aide in the classroom. Margarita understands the conditions, limitations, and capacity specifications of the Facility license. Margarita understands that children shall be visually supervised at all times. LPA observed a Lysol can on a teacher's desk accessible to children and a crate with several cans of Lysol and Clorox wipes next to the classroom sink/drinking fountain accessible to children. Margarita states the Facility is cleaned by school janitorial services. Children bring there water containers from home and Margarita states the facility has additional water bottle if needed. LPA observed a solid waste container without a tight-fitting lid in the playground with food and drink containers in it. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff toilet not utilized by the children which an isolated child can use if needed. Margarita states that there are no weapons or firearms on the premises.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. Cleaning supplies are inaccessible to the children and stored in high cabinets inaccessible to children. Any poisons are stored in locked storage cabinets. Any medications at the Facility are stored in the director's office area. No IMS is administered by the Facility.

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 and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. LPA observed a mop bucket in the playground full of water. A canopy and the building overhang provide shade for the day care children.

Exit interview conducted and report was reviewed with the Director Margarita Carrillo-Gaitan.


The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
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: ASJUSD/SAN JUAN MI ESCUELITA PRESCHOOL
FACILITY NUMBER: 354413128
VISIT DATE: 12/12/2022
NARRATIVE
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LPA Deanna Villagrana informed Director Margarita Carrillo-Gaitan that this report dated 12/12/2022 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Deanna Villagrana informed the Director Margarita Carrillo-Gaitan to provide a copy of this licensing report dated 12/12/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2022 01:39 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ASJUSD/SAN JUAN MI ESCUELITA PRESCHOOL
FACILITY NUMBER: 354413128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239(f)(1)
Fixtures, Furniture, Equipment and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof.

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. LPA observed a solid waste container without a tight-fitting lid in the playground with food and drink containers in it which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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Director had janitor place a garbage lid over garbage can during visit. Deficiency cleared today.
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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. Staff 1 and 3 are missing LIC501 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2023
Plan of Correction
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Director will submit LIC501 for staff 1 and 3 to CCLD by POC date.
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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 12/12/2022 01:39 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ASJUSD/SAN JUAN MI ESCUELITA PRESCHOOL
FACILITY NUMBER: 354413128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(b)(2)
Child's Medical Assessments
(b) The medical assessment shall provide the following: (2) Results of a test for tuberculosis.

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. Child 4 and 5 are missing TB test results which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2023
Plan of Correction
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Director will submit TB test for child 4 and 5 to CCLD by POC date.
Type B
Section Cited
CCR
101221(b)(6)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 101219.

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. Child 8 and 10 are missing a signed Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2023
Plan of Correction
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Director will submit a signed Admission Agreement for child 8 an 10 to CCLD by POC date.
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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2022 01:39 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ASJUSD/SAN JUAN MI ESCUELITA PRESCHOOL
FACILITY NUMBER: 354413128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

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. Child 1 is missing LIC627 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2023
Plan of Correction
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Director will submit LIC`627 for child 1 to CCLD by POC date.
Type B
Section Cited
CCR
101221(b)(a)


This requirement is not met as evidenced by: Medical assessment, including ambulatory status as specified in Section 101220, and the following health information:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above Child 5 is missing Health History form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2023
Plan of Correction
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Director will submit Health History form for child 5 to CCLD by POC date.
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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2022 01:39 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ASJUSD/SAN JUAN MI ESCUELITA PRESCHOOL
FACILITY NUMBER: 354413128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101238(g)


This requirement is not met as evidenced by: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a Lysol can on a teacher's desk accessible to children and a crate with several cans of Lysol and Clorox wipes next to the classroom sink/drinking fountain accessible to children which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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Director removed items and placed them in a locked shelf above sink. Deficiency cleared today.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 12/12/2022 01:39 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ASJUSD/SAN JUAN MI ESCUELITA PRESCHOOL
FACILITY NUMBER: 354413128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(a)(2)


This requirement is not met as evidenced by: The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. (2) The licensee shall safely dispose of water and any disinfectants/solutions that have been used for cleaning.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a mop bucket in the playground full of water which poses/posed a potential health, safety or personal rights risk to persons in care. Janitor stated the bucket belongs to an outside janitorial service that was terminted in January 2022. He stated he is unsure if bucket had chemicals or not.
POC Due Date: 12/12/2022
Plan of Correction
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3
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Director dumped out water during visit. Deficiency cleared today.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
LIC809 (FAS) - (06/04)
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