430703796-10-26-2022-07-CC-AMOS-CKKSW4-20221026141341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430703796
Report Date: 10/26/2022
Date Signed: 10/26/2022 02:13:59 PM

Document Has Been Signed on 10/26/2022 02:13 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:	MISSION COLLEGE CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	430703796
ADMINISTRATOR:	NAVARRO, KARIN		FACILITY TYPE:	850
ADDRESS:	3000 MISSION COLLEGE BLVD MS#6		TELEPHONE:	(408) 855-5177
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95054
CAPACITY:	90	CENSUS: 14	DATE:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Anne Horgan/Tricia Darrell		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Anna Morales conducted an ANNUAL REQUIRED visit. LPA was greeted by Director Anne Horgan and Program Specialist Tricia Darrell. Operating hours are Monday through Friday,9:00am-5:00pm. The Facility is licensed on the campus of Mission College in the following rooms: Room 3 - Tulips (toddler option) and Room 4 - Snapdragons, however, they are not currently open. Room 5 - Sunflowers, and Room 6 - Orchids remain open. The Facility also has an infant program (#434406682) on site and that program is licensed in Room 1 (Bluebell) and Room 2 (Roses) which is INACTIVE STATUS. LPA toured the indoor and outdoor space of the Facility during 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 (PUB 269), Menus, and Activity Schedule. In classroom 5, Sunflowers there are five children and one teacher and two student assistants In classroom 6- Orchids, there are nine children and three teachers. and one student assistant LPA observed that the teacher/child ratio was in compliance during today's inspection. Facility is Title 5 funded and thus Title 5 ratios apply There were no bodies of water observed. Director stated that facility do not have weapons on the premises. Furniture and equipment were observed to be age appropriate and in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, and other items that are dangerous to children were stored inaccessible to children. Floors were clean. (page 1)

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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 4

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: MISSION COLLEGE CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 430703796
	VISIT DATE: 10/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Outdoor activity space is enclosed by fencing and is observed to be free of hazards. LPA observed play equipment were in good condition. LPA observed resilient materials under the climbing structures. Drinking water was readily available to children indoor and outdoor. Facility provides breakfast, lunch and and two snacks. LPA observed that food storage areas were clean and free of litter. Foods and beverages were kept protected against contamination and spoilage. Trash cans for solid waste had tight-fitting covers on, and were in good repair.

Fire extinguisher, smoke and carbon monoxide detectors were observed. The fire alarms and smoke detectors are hardwired.

This facility is providing Incidental Medical Services – IMS Plan. There is an isolation area being used for Isolation (if a child gets sick while at the center while waiting for parent pick up). Director stated that there are children who have medication at the center. Supporting documentation and medications were reviewed.

LPA reviewed sign in and out record, and procedure. Children records reviewed include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, Medical Assessment, Immunization.

LPA reviewed a random selection of Staff records reviewed include Health Screening Report and TB test, Immunization (Measles, Pertussis, and Flu) record and required Training. LPA reminded Director that the online AB1207 Mandated Reported Training needs to be renewed every two years. There was at least one person with current certification in Pediatric CPR and First Aid present at the facility.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: MISSION COLLEGE CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 430703796
	VISIT DATE: 10/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Exit interview conducted and report was reviewed with the Anne Horgan and Trisha Darrel. California Code of Regulations, (Title 22, Division 12 & Chapter 1), are being cited on the attached LIC 809-D. Appeal Rights Given.

NOTICE OF SITE VISIT WAS ISSUED. DIRECTOR WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.

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/inspection-process

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/26/2022 02:13 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MISSION COLLEGE CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 430703796
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101226(e)(3)(A)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review Staff did not comply with the section cited above with C2 Centrally Stored Medicaiton(s).C2 EPI- PEN expired on 7/2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2022
	Plan of Correction
1 2 3 4	Director agreed to give expired EPI Pen to C2 parents and obtain a new one. Director will submit a photo of the New EPI- PEN with expiration date and a picture of C2'S NAME

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Gladys Kuizon	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4