434403619-11-19-2019-07-CC-AALZ-BJ422U-20191119160119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434403619
Report Date: 11/19/2019
Date Signed: 11/19/2019 04:01:30 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:	HAYES STATE PRESCHOOL CDC		FACILITY NUMBER:	434403619
ADMINISTRATOR:	DIANA RAMOS		FACILITY TYPE:	850
ADDRESS:	5035 POSTON DRIVE		TELEPHONE:	(408) 629-1185
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	48	CENSUS:	DATE:	11/19/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:43 PM
MET WITH:			TIME COMPLETED:	04:15 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 Annual Random Inspection was conducted on this day, by Licensing Program Analyst (LPA) Almaraz, Araceli. Facility is currently licensed for a capacity of 48. Licensing staff met with Director Ramos, Diana. The program currently operates for Preschool 9AM to 12PM, Monday through Friday and for School Age 6:30AM to 8AM and 1:20PM to 6PM, 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 is a total census of 37 children and a total census of four teachers/staff present. LPA observed all the required posted materials. PHYSICAL PLANT This is a preschool and school age program which consists of classrooms; one split portable RM A and RM B. The Site Supervisor understands that the School Age program may not co- mingle with the Preschool program at any time. All areas identified on the Facility Sketch were inspected. Room A: The following was observed of this room during the inspection of the facility: Upon arrival, RM A had one teacher, one aide and 24 school age children. There is one toilet, one facet and two sinks in this room. Teacher-child ratios were observed and staff names recorded. Room B: The following was observed of this room during the inspection of the facility: Upon arrival, RM B had one teacher, and 13 school age children. There is one toilet, one facet and three sinks in this room. Teacher-child ratios were observed and staff names recorded. Furniture and equipment were inspected for age appropriateness and are in sufficient condition. Telephone service, heating, lighting and ventilation were evaluated. ***Page 1/4, Report continued on Page 2***

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

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: HAYES STATE PRESCHOOL CDC	FACILITY NUMBER: 434403619
	VISIT DATE: 11/19/2019

NARRATIVE

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Director Ramos was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. The fire extinguishers 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. 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

Exit interview conducted, copy of report was given.

NOTICE OF SITE VISIT ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS,
*****Page 4/4, Final Page of Report Continued from Page 3*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: HAYES STATE PRESCHOOL CDC	FACILITY NUMBER: 434403619
	VISIT DATE: 11/19/2019

NARRATIVE

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Teacher-child ratios were observed and staff names recorded. Care and supervision was evaluated to determine if the basic needs of children are met and appropriate. Sign-in and out sheets and procedures were reviewed. Personal Rights of children were observed by LPA.

Staff and Children’s Records were reviewed. Criminal Record Clearances were reviewed for adults
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.
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.

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 Ramos:
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.

*****Page 3/4, Report Continued on Page 4*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

LIC809 (FAS) - (06/04)

Page: 4 of 4

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: HAYES STATE PRESCHOOL CDC	FACILITY NUMBER: 434403619
	VISIT DATE: 11/19/2019

NARRATIVE

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Children have their own cubby to store their belongings. Per director, the isolation area is in the Directors office. 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 Ramos states that poisons are locked under sink. First Aid supplies were observed in the classrooms, in cabinet. According to Director, medication is only administered to a child when accompanied with a doctor's note and is stored in the kitchen in a medication box. Carbon monoxide detectors and smoke detectors are and working present in the facility. There is one Fire extinguisher size 3A40BC per room. both serviced on 02/14/2019. Last fire drill conducted on 10/30/2019.

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. Snack/lunch menus were reviewed. Food and snacks were reviewed for availability, quantity and appropriateness to children in care. Food preparation areas were toured for safety, cleanliness and proper equipment. Breakfast/Lunch and AM/PM snacks served depending on the times of children in care. All meals are prepared in Room B where kitchen is located.
Lavatories:
Age appropriate sinks and toilets were inspected for availability and sufficient condition in all lavatory. LPA observed age appropriate sinks and toilets and were inspected for availability, water temperature, toilet paper, area safety and sanitation. LPA Almaraz observed the children's sinks are in working condition and meet licensing standards. LPA Almaraz observed soap dispenser and disposable towels in the preschool/school age bathrooms. Staff uses main office lavatory.

Outdoor playground equipment is in a safe condition, free of sharp, defective or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, swings, slides, and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard in a near by tree area. There is a pop up canopy that is used depending on weather kept in a locked shed in close proximity. Availability of outdoor drinking water was observed. Director states that this play area is used from 9:00 AM to 12:00 PM, this area is exclusive to preschoolers. There is a shared kindergarten/school age playground that is property of Oak Grove School district. Supervision and schedule differentials ensures there is no commingling. *****Page 2/4, Report Continued on Page 3*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

LIC809 (FAS) - (06/04)

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