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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416166
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:07:53 PM

Document Has Been Signed on 11/04/2022 04:07 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:MEADOWLARK PRESCHOOL LLCFACILITY NUMBER:
354416166
ADMINISTRATOR:CHRISTINA CASTANEDAFACILITY TYPE:
850
ADDRESS:400 ISABEL LANETELEPHONE:
(408) 500-5000
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 90TOTAL ENROLLED CHILDREN: 65CENSUS: 50DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Meadowlark Preschool LLCTIME COMPLETED:
04:15 PM
NARRATIVE
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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, Christina Castaneda and explained the nature of today's visit to her. Owner Heidi Nelson arrived to assist Christina with report. The Facility is licensed in rooms 1, 2 and 3 at Seventh Day Adventist School campus. The playground area of the Facility is located to the right of the of the building. There are no active waivers at this time.

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.

A review of staff records on 10/31/2022 indicates that not all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Staff Gisselle Gonzalez is not associated to the facility. Director Christina 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.


LPA reviewed ten children's and six staff (1 director & 4 teachers & 1 aide) files during today's inspection. Staff 2, 3 and 6 do not have a current Mandated Reporter Certificate on file. Staff have a valid CPR and First Aid certification but is not EMSA approved on file. Director and four teachers reviewed contain the required transcripts/verification of experience. Christina 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). Child 2 does not have LIC995, Physician's Report and Admission Agreement.
Mary Segura
Deanna Villagrana
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: MEADOWLARK PRESCHOOL LLC
FACILITY NUMBER: 354416166
VISIT DATE: 11/04/2022
NARRATIVE
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LPA observed that the teacher/child ratio was not in compliance during today's visit. LPA observed 34 preschool children with one teacher and one aid in one class and 16 children with two teachers in another classroom. Facility was out of ratio. Christina understands the conditions, limitations, and capacity specifications of the Facility license. Christina understands that children shall be visually supervised at all times. LPA observed that all rooms are clean and safe for all children and staff. Christina states that the Facility staff clean rooms daily and an outside janitorial service cleans facility in the evenings. Drinking water is readily available for the children in each room and in the outdoor playground area via water dispensers. Children bring there out water containers to fill. LPA observed solid waste containers with tight-fitting lids in the Facility. 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. Christina 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. Several tarps and the building overhang provide shade for the day care children. LPA did not observe any bodies of water.

Exit interview conducted and report was reviewed with the Owner Heidi Nelson.

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 Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
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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: MEADOWLARK PRESCHOOL LLC
FACILITY NUMBER: 354416166
VISIT DATE: 11/04/2022
NARRATIVE
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LPA Deanna Villagrana informed owner Heidi Nelson that this report dated 11/04/2022 document(s) 2 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 owner Heidi Nelson to provide a copy of this licensing report dated 11/04/2022 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 Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2022 04:07 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 11/04/2022 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEADOWLARK PRESCHOOL LLC
FACILITY NUMBER: 354416166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or

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 Gisselle Gonzalez is not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2022
Plan of Correction
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Director Christina Castaneda will associated Gisselle Gonzalez proir to her returning to work at faciity.
Type A
Section Cited
CCR
101216.3(a)
Teacher-Child Ratio
(a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.

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 34 preschool children with one teacher and one aid in one class which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2022
Plan of Correction
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Director Christina Castaneda will submit a statement stating how she will ensure facility stays within ratio at all times.
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 Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


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Document Has Been Signed on 11/04/2022 04:07 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 11/04/2022 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEADOWLARK PRESCHOOL LLC
FACILITY NUMBER: 354416166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 2, 3 and 6 do not have a current Mandated Reporter Certificate on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Director will submit a current Mandated Reporter training for staff to CCLD by POC date.
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

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. No staff have a valid CPR and First Aid certification that is EMSA approved on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Director will submit a EMSA approved CPR/1st Aid certificate for at least one staff 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 Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/04/2022 04:07 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 11/04/2022 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEADOWLARK PRESCHOOL LLC
FACILITY NUMBER: 354416166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

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 2 is missing Physicians Report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Director will submit Physician's Report for child 2 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 2 is missing Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Director will submit Admission Agreement for child 2 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 Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


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Document Has Been Signed on 11/04/2022 04:07 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 11/04/2022 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEADOWLARK PRESCHOOL LLC
FACILITY NUMBER: 354416166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101218.1(e)(1)


This requirement is not met as evidenced by: The licensee shall keep a copy of the Acknowledgement of Receipt portion of the Caregiver Background Check Process form (LIC 995 [8/02]), signed by the child’s authorized representative, in the child’s file.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Child 2 is missing LIC995 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Director will submit LIC995 for child 2 to CCLD by POC date.
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 Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


LIC809 (FAS) - (06/04)
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