434400227-12-20-2019-07-CC-SYIP-BK2VAM-20191220151609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434400227
Report Date: 12/18/2019
Date Signed: 12/20/2019 03:16:13 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:	NORDSTROM STATE PRESCHOOL		FACILITY NUMBER:	434400227
ADMINISTRATOR:	LORENA DOMINQUEZ		FACILITY TYPE:	850
ADDRESS:	1425 E. DUNNE AVENUE		TELEPHONE:	(408) 778-2821
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	24	CENSUS: 9	DATE:	12/18/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Lorena Dominquez		TIME COMPLETED:	10:12 AM

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) Samantha Yip conducted an unannounced annual random inspection. Upon arrival, LPA met with Ralph Cortrez, Teacher, and explained the reason for the inspection. Present during today's inspection were 3 staff and 9 children. The teacher child ratio was observed to be in compliance during today's inspection. Facility is located on the Nordstrom Elementary School campus and currently only uses one of the portables for the preschool. The hours of operation are Monday through Friday 8AM-11AM. Licensee, Emergency Disaster Plan, and Notification of Parent's Rights were observed during today's inspection. LPA reviewed the sign in/sign out sheet, which contains full legal signature. LPA toured in the inside and outside of the facility. The facility was observed to clean and sanitary. Furniture and equipment, such as chairs and tables, were age appropriate. Disinfectant, cleaning supplies, and other items that are dangerous to children were observed to stored inaccessible to children in care. LPA observed that there is sufficient amount of toys for children in care. Restroom for children's use was observed to be clean. Storage containers for waste have tight fitted lids. LPA observed a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. Director stated that there are no weapons, such as firearms, stored on the premise. The outdoor activity area is fenced. Play structure, equipment, and toys were observed to be in good condition. Area around play structure have resilient material to absorb falls. Shaded rest area is provided through trees. There were no bodies of water observed during today's inspection. LPA reminded Director to dump any water that collect before children go outside. -----------------------continues on 809 dated 12/18/2019 page 2-----------------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019

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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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: NORDSTROM STATE PRESCHOOL	FACILITY NUMBER: 434400227
	VISIT DATE: 12/18/2019

NARRATIVE

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----------------continuation of 809 dated 12/18/2019 page 1---------------------------------------

Facility does provide snacks to the children in care. Menu was posted. Kitchen used to prepare snacks was observed to be clean and sanitary. Drinking water is provided through water pitcher and cups.

5 children's file were reviewed during today's inspection. The records reviewed include but not limited to physician report.

2 staff files were reviewed during today's inspection. The records reviewed include but not limited education credit and Mandated Reporter Training. LPA reminded Director that Mandated Reporter Training required renewal every 2 years. Staff have a valid CPR/1st Aid. All staff present have cleared criminal record clearance and child abuse index.

Director stated that she currently does not have any children in care who requires Incidental Medical Services (IMS).

In the areas that were evaluated, no deficiencies have been cited. An exit interview was conducted where this report was discussed and provided to Director. A notice of site visit has been issued and must be posted for 30 consecutive days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019

LIC809 (FAS) - (06/04)

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