430710463-3-12-2020-07-CC-AALZ-BMMVAV-20200312161635

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430710463
Report Date: 03/12/2020
Date Signed: 03/12/2020 04:16:47 PM

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:	WILLIAMS SCHOOL AGE CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	430710463
ADMINISTRATOR:	WHITNEY LUKANC		FACILITY TYPE:	840
ADDRESS:	1150 RAJKOVICH WAY		TELEPHONE:	(408) 997-8703
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95120
CAPACITY:	70	CENSUS: 37	DATE:	03/12/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Lukanc, Whitney		TIME COMPLETED:	04:21 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	An unannounced 1 Year Required Inspection was conducted on this day, by Licensing Program Analyst (LPA) Almaraz, Araceli. Facility is currently licensed for a capacity of 70. Licensing staff met with Director Lukanc, Whitney. The school age program currently operates 6:30AM to 6:00PM, Monday through Friday. The program generally has AM children from 6:30AM to 8:45 AM, and PM children from 3PM to 6 PM, Monday through Friday. Licensing staff was taken on a guided tour of the facility of both indoors and outdoors. At the initial start of this visit, there was a total census of 37 children and a total census of four teachers/staff, including Director present. PHYSICAL PLANT: This is a school age program which consists of the following classrooms; Room O and Room Y. This is a shared/split portable. All areas identified on the Facility Sketch were inspected. Upon arrival, the following staff were present during this inspection: Room O: Staff #1 and #2 with 20 children. Room Y: Staff #3 and #4 with 17 children. Teacher/child ratios observed. The following was observed of rooms during the inspection of the facility: Room O: There is one toilet, one wash basin, one sink and one facet. Teacher/child ratios observed. Room Y: There is one toilet, one wash basin, one sink and one facet. Teacher child/ratios observed. All Staff named recorded. The following is a summary of the rooms: Furniture and equipment were inspected for age appropriateness and are in sufficient condition. Telephone service, heating, lighting and ventilation were evaluated. Children have their own cubby to store their belongings in room Y, Room O children have lockers. Per director, the isolation area is in the office. 1/5

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020

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 5

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: WILLIAMS SCHOOL AGE CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 430710463
	VISIT DATE: 03/12/2020

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

General sanitation was observed. Availability of indoor drinking water was observed in classrooms. Disinfectants, cleaning solutions, medication and other hazardous items that pose a risk to children, were inaccessible to the children in care. Director states that poisons are locked under sinks. First Aid supplies were observed in each classroom in a back pack, fanny pack and kits. According to Director, medication is only administered to a child when accompanied by a doctor's note. Any medication is stored in both rooms in kitchen cabinets in a locked box. Carbon monoxide detectors and smoke detectors are and working present in the facility. There is a Fire extinguisher size 3A40BC in each room; last serviced on 01/20/2020. All required postings displayed, including license and parents rights.

Lavatories: Staff lavatory is in cafeteria and can be used for isolation for sick children if necessary. Age appropriate sinks and commodes/toilets were inspected for availability and sufficient condition in all lavatories. LPA inspected for availability, water temperature, toilet paper, area safety and sanitation. LPA observed soap dispenser and disposable towels in the preschool lavatories. The number of commodes/toilets, washbasins, sinks and facets per child ratios met.

Food preparation: All kitchen areas/food preparation areas and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. All storage containers for solid waste, including moveable trash receptacles have tight-fitting covers that are kept on, and in standard condition. Director states waste is to be discarded immediately after each meal. Snack/lunch menus were reviewed for availability, quantity and appropriateness to children in care. Food preparation areas were toured for safety, cleanliness and proper equipment. Breakfast served daily for AM children. PM snack served for PM children. Food prepared on site. In the event of allergies or special dietary needs, breakfast and/or PM snack can be brought from home. Menus posted one week in advance where parent/guardian can review items. Menus available up to one year upon request. 2/5

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: WILLIAMS SCHOOL AGE CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 430710463
	VISIT DATE: 03/12/2020

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

Playground: Outdoor equipment was inspected for safety, cushioning material, good repair and appropriateness. Required shade, drinking water and fencing were inspected. LPA advised Director that the children need to be within the direct care and supervision, including visual supervision of the teacher(s) at all times. The children have access to drinking water during outside play. Play area was inspected for hazards and inaccessibility to bodies of water; no bodies of water or hazards observed. There is slight repair needed on cushioned material.

Facility Records: Staff and Children’s Records were reviewed. All individuals present have obtained a criminal record clearance or criminal record exemption. There is at least one person trained in CPR and Pediatric First Aid present during this inspection. (All staff have received an active criminal record clearance as a condition of their employment.)

Children’s Records were reviewed for completeness; Inspection of required forms was made. LPA issued the Children’s Record Review (LIC 857) to the Director during this inspection. In review of children’s records, files contain information including, but not limited to the following: Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary. Admissions agreements reviewed, this includes inspection authority of licensing, the Department of Social Services; upon presenting proper identification to facility.LPA also issued the Review of Staff records (LIC 859) to the licensee during this inspection. The LIC 857 and the LIC 859 documents the staff and children’s files that were reviewed during this inspection.

Children's roster was reviewed and is current. Sign-In and Sign-Out sheets were reviewed. This facility uses an electronic sign in/out, kinder sign. In addition, there is a departure list for sign in/sign out for teachers to conduct a name to face procedure. Children present were signed in. Disaster drill log was available, last drill was conducted on 02/25/2020 3/5

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: WILLIAMS SCHOOL AGE CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 430710463
	VISIT DATE: 03/12/2020

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

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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

The following was discussed with Director Lukanc.:
Rooms that are off-limits need to be made inaccessible during operating hours. Smoking is prohibited. No infant walkers, no Johnny Jumpers, no excersaucers or any other item that falls into that category are allowed in facility.

The Director was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed. LPA also provided a complete packet of the Provider Information Network (PIN) 10-02-CCP dated February 20, 2019 regarding Safe Sleep Awareness Campaign during today’s inspection.

The fire extinguisher type 2A10BC or larger must be serviced annually or as often as necessary. Smoke and Carbon Monoxide detectors should be checked and batteries replaced as needed. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your location.

Mandatory Forms for the children’s files and staff files, requirements for fire drills, earthquake drills and documentation were discussed. Role and responsibilities of being a Mandated Reporter were reviewed. 4/5

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020

LIC809 (FAS) - (06/04)

Page: 5 of 5

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: WILLIAMS SCHOOL AGE CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 430710463
	VISIT DATE: 03/12/2020

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

The Director was advised how to access forms and Regulations online at www.ccld.ca.gov. Director was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care. The Director was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care.

LPA advised Director that all adults 18 years of age and older providing Care & Supervision and/or have continuous presence in the facility shall adhere to a criminal background clearance with the Department of Justice, FBI and Child Abuse Index Check.

LPA informed Director to log onto web site www.ccld.ca.gov to obtain forms and LIVE SCAN application. Records for all children and staff must be maintained for three (3) years after separation from the facility.

The Director was also advised of the requirement to report Unusual Incidents and/or injuries to the parent/guardian and to CCL within the time frame specified by the regulation. Director advised to visit www.shotsforschool.org for immunization information.

Director advised that indoor and outdoor supervision required at all times. If outdoor area not adequately fenced, provider must be with children at all times when outdoors.

These forms may also be downloaded from our website: www.ccld.ca.gov

There were no deficiencies cited during today's visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1.

NOTICE OF SITE VISIT ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS. 5/5

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020

LIC809 (FAS) - (06/04)

Page: 4 of 5