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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404912
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:19:22 PM


Document Has Been Signed on 03/29/2022 03:19 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:ROSEMARY PRESCHOOLFACILITY NUMBER:
434404912
ADMINISTRATOR:HEATHER ELSTONFACILITY TYPE:
850
ADDRESS:401 WEST HAMILTON AVENUETELEPHONE:
(408) 341-7127
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:166CENSUS: 0DATE:
03/29/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Mylene IgnacioTIME COMPLETED:
03:20 PM
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Licensing Program Manager (LPM) Mary Segura and Licensing Program Analyst (LPA) Fermin Campos-Jaramillo met with Mylene Ignacio, Site Director, for a review of the following application forms on adding a toddler component.

Job descriptions: Multiple items need to be updated.
Staff handbook: Multiple items need to be updated.
Form LIC610: Updated form submitted.
Form LIC999: Update received today.
Menu: Provide snack menu, options to the preschool children.
Admission agreement: Missing basic services, and how parents can cancel the agreement. Options for meals. Add on supervision to children.
Infant needs: Changes to include the items in the sleeping plan form LIC9227 and signatures of parents/guardian and staff.
Family handbook Suggestion on changing to "admission agreement" or add an appendix for infants and toddlers. Plan on relocation in case of a disaster. Notices to parents on terminations. Updates on Appendix C and D, in reference of the SB792, addressed changes on food and services plan, volunteers need supervision from a fingerprinted cleared individual.

Ms Mylene Ignacio was provided with a detailed list of items that need to be changed or updated, and she agreed to submit a draft of the changes by next week.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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