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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430702544
Report Date: 11/10/2022
Date Signed: 11/10/2022 03:30:36 PM

Document Has Been Signed on 11/10/2022 03:30 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAMFACILITY NUMBER:
430702544
ADMINISTRATOR:BOBBI URBANOFACILITY TYPE:
840
ADDRESS:1425 LINCOLN AVETELEPHONE:
(408) 287-6999
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 200TOTAL ENROLLED CHILDREN: 130CENSUS: 112DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Bobbi UrbanoTIME COMPLETED:
04:00 PM
NARRATIVE
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On November 10th 2022 at 1:38pm , Licensing Program Analyst (LPA) Kassandra Medrano conducted a random annual licensing inspection today. LPA met with Bobbi Urbano, Director, the purpose of the visit was explained. The facility is located on a functioning public school site, Willow Glen Elementary School. Analyst inspected the facility building and grounds, conducted an evaluation of the physical plant, and reviewed children, staff and facility records. A review of staff records during today’s visit indicates that all staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Facility representative was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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. A $100.00 civil penalty per person per day up to 5 days (max $500 per person) for the first violation within a 12-month period will be assessed for individuals who do not have fingerprint clearances, are not associated to the facility, or have regular and routine contact with the daycare children. For Subsequent violations within a 12-month period, a civil penalty of $100 person per day up to 30 days (max $3000 per person) will be assessed for individuals who do not have fingerprint clearances, are not associated to the facility or have regular or routine contact with the daycare children. During review of clearances it was observed that facility had an individual that was not associated to the facility. Upon further discussion, Director stated that she had seen clearance of individual but had not associated them to the program. The program operates: Monday-Friday, 7am-6pm, specifically Morning session 7am-8:50pm, and afternoon session 2:50pm-6pm. The following was observed today:
Waivers on file for electronic sign in and out of children. Current rooms used for care P20, Library, Cafeteria all year round, as well as P18 and 19 during the summer. The following items were reviewed as part of today's visit: Care and Supervision of the Children, Child Discipline Procedures, Emergency Evacuation Procedures (smoke and carbon monoxide detectors present and in working order), Medication Policies, Isolation of Sick Children, Food Service, Transportation, Parents Rights, and Reporting Requirements.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAM
FACILITY NUMBER: 430702544
VISIT DATE: 11/10/2022
NARRATIVE
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Bathrooms for school age children are located within P20 as well as bathrooms across from playground. Supervision of school age children coming and going from the bathrooms and at the bathrooms is achieved by direct supervision. The outdoor play area is located outside of portables, as well as out near the cafeteria. Children are signed in to the facility by staff and out of the facility by parents through CuraCubby. Posting requirements for site visits were discussed as well as AB 633 requirements. Current forms and Title 22 Regulations can be obtained through the internet at www.ccld.ca.gov. Staff immunization are on file. Director was reminded that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. Influenza Declarations were also reviewed. LPA reviewed with facility representative the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted. Director was advised of the required annual pesticides training. For More information about changes to the Healthy Schools Act, templates, or articles, you can inspect the DPR website at:
https://apps.cdpr.ca.gov/schoolipm/childcare/training/main.cfm . Director was informed about the Provider Information Notices (PINs) on CCLD website. During review of files it was observed that 6/7 staff were missing the mandated reporter training. Director was reminded of Mandated Reporter Training available on CCLD website. Training must be renewed every two years. 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 Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
Exit interview conducted and report was reviewed with the facility representative, Bobbi.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):

"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS. MUST REMAIN POSTED FOR THIRTY DAYS. PROVIDER UNDERSTANDS THIS REQUIREMENT.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
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Document Has Been Signed on 11/10/2022 03:30 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 11/10/2022 at 03:07 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: WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAM
FACILITY NUMBER: 430702544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022

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 in 6/7 staff files that were reviewed were missing this training which poses 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 to send documentation of staff completion of the required training.
Type B
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 interview and record review, the licensee did not comply with the section cited above in 1 staff, Sara Pacheco was not associated which 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 to associate staff to facility through guardian.
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:Diana Stephenson
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022


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