430710593-10-6-2021-07-CC-JMAS-C7JV82-20211006161201

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430710593
Report Date: 10/06/2021
Date Signed: 10/06/2021 04:12:26 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:	SJB - CHERRYWOOD EXTENDED DAY CARE		FACILITY NUMBER:	430710593
ADMINISTRATOR:	DONNA CLUBB		FACILITY TYPE:	840
ADDRESS:	2550 GREENGATE DRIVE		TELEPHONE:	(408) 259-9739
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95132
CAPACITY:	53	CENSUS: 24	DATE:	10/06/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:09 PM
MET WITH:	Ofelia Saldivar		TIME COMPLETED:	04:25 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) Joe Macias conducted an unannounced Required - 1 Year Inspection (took kit #1). The purpose of today’s visit is to ensure the facility is in compliance with Title 22 California Code of Regulations. LPA met with the Head Teacher Ofelia Saldivar, and explained the nature of today's visit. The after school center is located on the Cherrywood Elementary School campus, in one of the portables. The portable is divided into 2 rooms. Room 1 is used for children who are currently in Kindergarten to Second Grade. Room 2 is for children who are in Grade 3 and above. LPA toured the Facility both inside and outside during todays visit. 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 hours of operation are Monday - Friday, 7am - 6pm, serving children ages 5-12 years.

LPA reviewed four children's and four staff files during today's visit. Each child's file reviewed contains the Information and Emergency Information form (LIC 700), immunization records, physicians report, personal rights, and parents rights. All staff files contain the required transcripts/verification of experience. All staff's CPR and First Aid certifications are current. The Director understands that there shall be at least one person with valid CPR and First Aid certifications on site at all times, or present during off-site activities (field trips).

Director understands the conditions, limitations, and capacity specifications of the Facility license. Director understands that children shall be visually supervised at all times. LPA observed that all rooms are clean and in order. Drinking water is readily available for the children in each room and in the outdoor playground area via water dispenser, pitchers and cups. LPA observed solid waste containers with tight-fitting lids in each room. Staff and children's bathrooms are clean, sanitary. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Director states that there are no weapons or firearms on the premises.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Joseph Macias	TELEPHONE: (408) 334-8320
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

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 2

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: SJB - CHERRYWOOD EXTENDED DAY CARE	FACILITY NUMBER: 430710593
	VISIT DATE: 10/06/2021

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

The food preparation and storage areas are clean, free of litter, rubbish, free of rodents, and other vermin. Cleaning supplies are securely stored and inaccessible to the children. LPA observed a fully charged 2A10BC fire extinguisher, and working smoke/carbon monoxide detectors. Director states that the Facility does not administer medications at this time.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by children is surrounded by appropriate fencing. LPA observed that the outdoor equipment is age appropriate. LPA did not observe any bodies of water.

A review of staff records on October 6, 2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded Licensee 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. A $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected.

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.

LPA observed staff immunization records on file.

All staff have completed the Mandated Reporter Training.

No deficiencies cited, exit interview conducted, and a copy of this report was left at the facility.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Joseph Macias	TELEPHONE: (408) 334-8320
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2