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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710435
Report Date: 08/29/2019
Date Signed: 08/29/2019 09:48:48 AM

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:MONTAGUE DISTRICT/STATE PRESCHOOLFACILITY NUMBER:
430710435
ADMINISTRATOR:GINA PEREZFACILITY TYPE:
850
ADDRESS:750 LAURIE AVENUETELEPHONE:
(408) 423-1931
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY:120CENSUS: 17DATE:
08/29/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Gina PerezTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Shannel Reed conducted an unannounced Case Management- Incident investigation. LPA met with Director, Gina Perez, and explained the reason for the inspection.
LPA notes that the Facility is located on the campus of Montague Elementary School. The State Preschool is located in Rooms 27 & 26 and the District Preschool is located in Room 28. The State Preschool is an AM program and is only in operation from 8:30 AM to 11:30 AM Monday to Friday. The District Preschool is open from 7 AM to 6 PM Monday to Friday. The program is operated by the Santa Clara Unified School District and all criminal background checks for staff are handled by the Department of Education and thus do not come under the jurisdiction of Community Care Licensing Division.
The purpose of the inspection was to review two self- reported incidents. One incident occurred on 07/12/19 that involved C-1, where an injury occurred. And an incident that occurred on 07/15/19 that involved C-2, no injuries occurred with this incident.
LPA interviewed the Director. The additional staff that were involved in the incidents are no longer working at this facility. LPA also discussed with the Director about incidents in further detail and the corrective action that had been taken following these incidents. The Director explained in the procedural changes that have been adopted following theses incidents.
Based on information obtained, LPA determined that additional information is needed.

No deficiencies have been cited as a result of this inspection. An exit interview was conducted with Director.

A Notice of Site Visit has been issued and must be posted for 30 consecutive days.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Shannel ReedTELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2019
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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