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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416166
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:15:26 PM

COMPREHENSIVE INSPECTION
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:90CENSUS: 44DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Christina CastanedaTIME COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA), Deanna Villagrana conducted an unannounced required 1 year inspection to the Facility today. LPA met with Christina Castaneda, director, and explained the nature of today's visit to her. 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 classrooms.

LPA toured the Facility both inside and outside for today's inspection. LPA observed the required posted materials, including the Facility License and Emergency Disaster Plan (LIC 610). LPA did not observe the following Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law, Menus, and Activity Schedule. LPA

A review of staff records on 06/15/2021 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 Christina of the applicable civil penalties 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. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violations within a 12 month period.

LPA reviewed ten children's and five staff (3 teachers and 2 aids) files during today's inspection. All staff are missing Mandated Reporter Training. Staff 2 and 4 are missing LIC503. Staff 2, 3, and 4 are missing LIC508. Staff 2 and 3 are missing LIC9052. Staff 4 and 5 are missing immunization records. Staff 4 has a current CPR and First Aid certifications on file. Three staff files (3 teachers) reviewed contain the required transcripts. Verification of experience is needed. Child 7 and 9 are missing Admission Agreements. 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).

LPA observed that the teacher/child ratio was in compliance during today's visit. LPA observed 44 preschool children with three teachers and two aides in the playground. Christina understands

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

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 9
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: 06/23/2021
NARRATIVE
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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. LPA observed Clorox Cleaner, Clorox wipes, carpet shampoo, respiratory blend and sunscreen accessible to children. All items are labeled, 'Keep out of reach of children'. Christina states that the Facility has an after hour janitorial service who cleans the facility. Children bring their drinking water from home. 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. 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. Building overhang and a canopy provides shade for the day care children. LPA did not observe any bodies of water.

The following type A and B deficiencies were cited on the attached page (809-D). Christina 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.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Christina. A copy of this report and appeal rights were discussed and left with Christina, whose signature on this form confirms receipt of these documents.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FACILITY ENTRANCE WERE PARENTS CAN SEE, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 9
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2021
Section Cited

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Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. This requirement was not met as evidenced by
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LPA observed Clorox Cleaner, Clorox wipes, carpet shampoo, respiratory blend and sunscreen accessible to children.
This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.

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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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 3 of 9
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2021
Section Cited

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Each licensee shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. This requirement was not met as evidenced by LPA did
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not observe Earthquake Preparedness Checklist (LIC 9148).
This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
06/23/2021
Section Cited

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Admission Procedures – Parents Rights. The licensee shall post the Child Care Center Notification of Parents’ Rights poster (PUB 393[8/02]) in a publicly accessible place at all times. This requirement
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 was not met as evidenced by LPA did not observe Parents' Rights Poster (PUB 393).
This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 4 of 9
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2021
Section Cited

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The center shall post a copy of the LIC 613A (9/96) in a prominent, publicly accessible area in the center. This requirement was not met as evidenced by LPA did not observe Personal Rights (LIC 613A)
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
06/23/2021
Section Cited

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The licensee shall post signs at the entrance to the child care center that provide the telephone number of the local health department and information on child passenger restraint systems pursuant to Health and Safety Code section 1596.95(g) and Vehicle Code sections 27360 and 27360.5
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This requirement was not met as evidenced by LPA did not observe Child Car Seat Law. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 5 of 9
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2021
Section Cited

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Menus shall be in writing and shall be posted at least one week in advance in an area accessible for review by the child's authorized representative. Copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the child's authorized representative and the Department upon request.
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This requirement was not met as evidenced by LPA did not observe the menu. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
06/30/2021
Section Cited

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(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This requirement was not met as evidenced by Staff 2 and 4 are
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missing LIC503.
This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 6 of 9
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2021
Section Cited

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(d) All individuals subject to criminal record review shall, be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidenced by
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Staff 2, 3, and 4 are missing LIC508. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
06/23/2021
Section Cited

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A copy of the signed LIC 9052 (11/94) shall be kept in the employee's personnel record. This requirement was not met as evidenced by Staff 2 and 3 are missing LIC9052.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 7 of 9
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2021
Section Cited

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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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This requirement was not met as evidenced by Staff 4 and 5 are missing immunization records. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
06/30/2021
Section Cited

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The licensee and the child's authorized representative shall jointly complete a current individual written admission agreement for the child. This documentation shall be maintained at the child care center and shall be available for review.
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This requirement was not met as evidenced by Child 7 and 9 are missing Admission Agreements. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 8 of 9
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2021
Section Cited

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1596.8662(b)(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child 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
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complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement was not met as evidenced by All staff are missing Mandated Reporter Training. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 9 of 9