434400414-2-1-2023-07-CC-KMEO-CNN29A-20230201161138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434400414
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:11:51 PM

Document Has Been Signed on 02/01/2023 04:11 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	WILLOW GLEN ACADEMY		FACILITY NUMBER:	434400414
ADMINISTRATOR:	BOUTHELLIER, RANDOLPH		FACILITY TYPE:	850
ADDRESS:	1590 MINNESOTA AVENUE		TELEPHONE:	(408) 266-8056
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	25	CENSUS: 16	DATE:	02/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:47 PM
MET WITH:	Randolph Bouthellier		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	On February 1st, 2023 at 1:47pm, Licensing Program Analysts (LPAs) Kassandra Medrano and Ashley Davis met with Randolph , director, for an unannounced required – 1-year annual inspection. LPAs toured the indoor and outdoor areas of the Facility during today's inspection. 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), menus, and Activity Schedule. Days and hours of operation are: Monday through Friday, 6:30am-6:30pm. OFF LIMIT AREAS:Family room, living room, master bedroom, and master bath. The following was observed today: LPAs reviewed ten children's and 4 staff files during today's inspection. Each child's file reviewed contains the required documents, including the Information and Emergency Information form (LIC 700) and immunization records. Staff files reviewed contain the required documents, including transcripts/verification of experience/immunization records, and Health Screening Report. All staff were missing current certificates of completion of the Mandated Reporter Training for Child Care Workers on file. Last fire/disaster drill was completed on 1/23/2023. The staff files that were reviewed have current CPR and First Aid certifications on file. Director/Facility Representative 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). LPA observed that the teacher/child ratio was in compliance during today's inspection. Director understands the conditions, limitations, and capacity specifications of the Facility license. Director understand that children shall be visually supervised at all times. Any child(ren) who exhibit symptoms of illness including, but not limited to, fever or vomiting, are not accepted in care. Any child(ren) who become ill during the day, shall be isolated in the director’s office area. LPAs observed that the Facility is clean, and sanitary, for children, staff, and visitors. LPAs observed that the front yard was being used as storage, LPAs spoke to director about correcting issues in yard prior to children's re-entry into yard. The Facility has adequate ventilation, including central air conditioning/heating. Director understands that the Facility must be kept free of flies and other insects & rodents. Drinking water is readily available for the children in the Facility and in the outdoor playground area via filtered water and personal water bottles. Staff and children's bathrooms are clean, sanitary, and operable. Director states that there are no weapons or firearms on the premises.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: WILLOW GLEN ACADEMY	FACILITY NUMBER: 434400414
	VISIT DATE: 02/01/2023

NARRATIVE

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The Facility has functioning carbon monoxide detectors in the facility. The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. Facility provides am/pm snacks, as well as breakfast and lunch. The Facility has trash cans with tight fitting lids for solid waste. Cleaning supplies are inaccessible to the children and stored in high cabinets inaccessible to children. LPAs observed a complete First Aid kit in the Facility, including a touch less thermometer. Director understands that smoking is not allowed on the Facility premises.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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 backyard area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. Shade is provided by trees and building overhangs in the playground. LPA did not observe any bodies of water. Director states that the Facility does not provide transportation.
Randolph, director, was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Exit interview conducted and report was reviewed with the Director, Randolph. No deficiencies cited during today's inspection. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC809 (FAS) - (06/04)

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