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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404916
Report Date: 11/26/2019
Date Signed: 11/26/2019 11:02:35 AM

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:TLC OF CUPERTINOFACILITY NUMBER:
434404916
ADMINISTRATOR:THERESA CAMPBELLFACILITY TYPE:
850
ADDRESS:10038 BRET AVENUETELEPHONE:
(408) 996-1866
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:48CENSUS: 12DATE:
11/26/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Theresa CampbellTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA), Marilou Monico, met with Site Director, Theresa Campbell, for an unannounced annual random inspection. LPA observed all required posted materials: License, Parent’s Rights, Emergency Disaster Plan, menus, Earthquake Preparedness Checklist, Child Passenger Safety Law, and activity schedule. The preschool program's days and hours of operation are Monday to Friday from 7:30 AM to 6:00 PM.

LPA inspected the building both indoor and outdoor. LPA observed that the facility was operating in compliance with teacher to children ratio requirement. Children were engaged in activities under the supervision of the teachers. Children and staff bathrooms are sanitary and operable. LPA observed trash can with tight fitting cover at the facility for the disposal of solid waste. Functioning carbon monoxide detector and smoke detector were observed at the facility. LPA did not observe any bodies of water. LPA reviewed six random children's files and five staff files. At least one staff member present during the inspection has current CPR/First Aid certifications. Per Site Director, there were no weapons on the premises. LPA reviewed sign in/out sheets and children's roster. LPA obtained copy of children's roster.

Outdoor activity space is enclosed by fencing. Shade is provided by trees and canopies. The areas around high climbing equipment have resilient material to absorb falls. Drinking water was readily available to children indoor via water dispenser and sippy cups and outdoor via drinking fountain. Facility provides snacks to the children. There is a kitchen at the facility for food preparation. The kitchen is equipped with refrigerator, microwave, and sink with hot and cold running water. Sanitation is by the hand washing. LPA observed that food storage areas were clean, free of litter, and rodents.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 11/26/19):
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: TLC OF CUPERTINO
FACILITY NUMBER: 434404916
VISIT DATE: 11/26/2019
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 11/26/19):

Staff present during the inspection have cleared criminal record and child abuse index clearances or exemptions. LPA also reminded Site Director of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

LPA discussed Senate Bill 792, AB 633, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years with Site Director. Licensing forms, Title 22 regulations, can be obtained through the internet at ww.ccld.ca.gov. Mandated Reporter Training can be accessed at www.mandatedreporterca.com.

Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility.

This facility has Incidental Medical Services (IMS) Plan submitted to Licensing . Site Director stated that none of the children currently enrolled were using Epipens and Inhalers..

As a result of this inspection, deficiencies were cited on the following page:



A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: TLC OF CUPERTINO
FACILITY NUMBER: 434404916
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2019
Section Cited

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MANDATED REPORTER TRAINING - On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training and shall complete renewal every two years following the date on which he or she completed the initial mandated reporter training.
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The above requirement is not met as evidenced by: Staff #3 and #5 have not completed the Mandated Reporter Training. This poses a potential risk to health and safety to children in care.
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Type B
01/09/2020
Section Cited

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Employee and Volunteer Immunization - Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. This requirement is not met as evidenced by: Licensee's Staff #1, #2, #3, and #4 are missing immunization in measles, pertussis, and influenza. Staff #5 is missing immunization in measles. This poses a potential risk to health and safety to children in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3