430710458-9-16-2021-07-CC-AMOS-C6WRQW-20210916131410

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430710458
Report Date: 09/15/2021
Date Signed: 09/16/2021 01:15:04 PM

Document Has Been Signed on 09/16/2021 01:15 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:	HUGHES STATE PRESCHOOL		FACILITY NUMBER:	430710458
ADMINISTRATOR:	ADRIANA SALAS		FACILITY TYPE:	850
ADDRESS:	4949 CALLE DE ESCUELA		TELEPHONE:	(408) 423-1517
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95054
CAPACITY: 44	TOTAL ENROLLED CHILDREN: 0	CENSUS: 11	DATE:	09/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Joanie Nellis		TIME COMPLETED:	12:40 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	(#1) Licensing Program Analyst (LPA) conducted an ANNUAL REQUIRED visit. The facility is located on the campus of Hughes Elementary School. LPA notes that the District Preschool is licensed in Room 25 and the State Preschool is located in Room 37. which operates a half day program from 8:15 am to 11:15am, Monday through Friday. during the calendar school year. All classrooms operate under Title 22 and Title 5 (State Preschool). LPA was greeted by Site Director Joanie Nellis and Teacher Amanda Barefield. 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),and Activity Schedule. 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. LPA was informed that the only classroom open is Room 37. Rooms 25,( District Preschool) is currently closed due to the COVID pandemic. In classroom 37, LPA observed 9 children with Site Director and one Teacher Amanda Barefield. LPA observed that the facility was operating in compliance with teacher to children ratio requirement. Children were engaged in activities. There were no bodies of water observed. There is one toilet and two sinks inside the classroom. 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)

SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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 3

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: HUGHES STATE PRESCHOOL	FACILITY NUMBER: 430710458
	VISIT DATE: 09/15/2021

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

Last fire drill was conducted on 8/30/21. Director stated that there is an isolation area while waiting for pick up by parents. 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 ( children bring there own water bottles). The elementary school cafeteria provides breakfast and snacks.
Trash cans for solid waste had tight-fitting covers on, and were in good repair. Fire extinguisher, smoke and carbon monoxide detectors were observed. They are hard wired.
This facility is providing Incidental Medical Services – IMS Plan. Director stated that there are no children currently enrolled using medication.

LPA reviewed sign in and out record, and procedure. LPA reviewed a random selection of children files. Children records reviewed , Identification and Emergency Contact, Medical Assessment and immunization.
LPA reviewed a random selection of Staff records reviewed include, Health Screening Report, immunization's and TB test. LPA reminded Teacher that the online AB1207 Mandated Reported Training needs to be renewed every two years. Director Nellis renewed her training on July 29,2021.

LPA reminded Director 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. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.
LPA also reviewed with Director the violations that would result in an immediate assessment of civil penalty in the amount of $500. Director encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.

SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: HUGHES STATE PRESCHOOL	FACILITY NUMBER: 430710458
	VISIT DATE: 09/15/2021

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

In the areas that were evaluated, there were no deficiencies cited.

LPA discussed the requirements of AB 633 with the Director and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

A copy of this report was provided to the facility at the conclusion of the inspection.

A Technical Violation was issued at today's visit and was discussed with Director

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.

SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3