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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404912
Report Date: 11/01/2022
Date Signed: 11/01/2022 04:13:36 PM

Document Has Been Signed on 11/01/2022 04:13 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: 180TOTAL ENROLLED CHILDREN: 112CENSUS: 51DATE:
11/01/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Mylene IgnacioTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), James Santos conducted an unannounced inspection at the Facility today to continue the Required 1 Year inspection. LPA met with Assistant Director, Mylene Ignacio. During today's visit, LPA reviewed staff and children's records.

LPA reviewed six (6) Children's records which include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, Medical Assessment and Immunization and care plan. LPA reviewed thirteen (13) staff records which include Immunization (Measles, Pertussis, and Flu) record, TB Clearance, CPR/First Aid and Mandated Reported Training, Curriculums and qualifications.

Clearances for individuals at this facility who require caregiver background checks are issued by the State Department of Education and County office of Education and do not come under the jurisdiction of Community Care Licensing Division.

The center provides Incidental Medical Services (IMS) and has a Plan of Operation that includes IMS that was submitted to the Department. The children's medications are stored in a lock box inaccessible to children. Per review of record, the center conducts emergency disaster drills monthly.

Assistant 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.


No deficiencies cited. Exit interview conducted. Report was reviewed and a copy was provided to Assistant Director, Mylene Ignacio.


NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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