434406744-9-8-2021-07-CC-AMOS-C6NL22-20210908082135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434406744
Report Date: 09/03/2021
Date Signed: 09/08/2021 08:21:45 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:	HORACE MANN STATE PRESCHOOL		FACILITY NUMBER:	434406744
ADMINISTRATOR:	CECILIA SANTOS-CHAVEZ		FACILITY TYPE:	850
ADDRESS:	55 N 7TH ST		TELEPHONE:	(408) 535-6237
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	24	CENSUS: 8	DATE:	09/03/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Dorothy Perez		TIME COMPLETED:	11:35 AM

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	(#1)Licensing Program Analyst (LPA) Anna Morales conducted an unannounced Annual inspection and was by Room Teacher, Dorothy Perez. and Irma Aguinaga Facility’s License, Parents’ Rights Poster, Personal Rights, Activity Schedules and Menus were observed to be posted. Facility's operating days and hours are Monday to Friday in two sessions: Morning 8:00 AM - 11:00 AM and Afternoon 12:00 PM - 3:00 PM in Room 113. There are active waivers on file for use of elementary school bathroom and playground. The preschool is located in the premises of Horace Mann Elementary School and operates under the San Jose Unified School District. All staff have Caregiver Background Checks issued by the State Department of Education. LPA toured the facility both indoor and outdoor. There were eight students and two teachers present. Children were engaged activities. LPA observed that the facility was operating in compliance with teacher to children ratio requirement. There were no bodies of water observed. Teacher stated that facility do not have weapons on the premises. Furniture and equipment were observed to be age appropriate and in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, and other items that are dangerous to children were stored inaccessible to children. Floors were clean. Outdoor activity space is enclosed by fencing and is observed to be free of hazards. LPA observed play equipment were in good condition. LPA observed resilient materials under the climbing structures. Drinking water was readily available to children indoor and outdoor. Activities schedule and Menu were posted. The elementary school cafeteria provides breakfast, lunch and snacks (morning and afternoon). Page 1

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

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: HORACE MANN STATE PRESCHOOL	FACILITY NUMBER: 434406744
	VISIT DATE: 09/03/2021

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
26
27
28
29
30
31
32

Trash cans for solid waste had tight-fitting covers on, and were in good repair. Fire extinguisher, smoke and carbon monoxide detectors were observed. They are hard wired.

This facility is providing Incidental Medical Services – IMS Plan. Teacher stated that none of the children currently enrolled are using medication.

LPA reviewed sign in and out record, and procedure. LPA reviewed a random selection of children files. Children records reviewed include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, Medical Assessment, Immunization.

LPA reviewed a random selection of Staff records reviewed include Criminal Record and Child Abuse Index Clearance, Health Screening Report and TB test, Immunization (Measles, Pertussis, and Flu) record and required Training. LPA reminded Director that the online AB1207 Mandated Reported Training needs to be renewed every two years. There was at least one person with current certification in Pediatric CPR and First Aid present at the facility.

LPA reminded Teacher 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. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.

LPA also reviewed with Teacher the violations that would result in an immediate assessment of civil penalty in the amount of $500. Teachers encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

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: HORACE MANN STATE PRESCHOOL	FACILITY NUMBER: 434406744
	VISIT DATE: 09/03/2021

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
26
27
28
29
30
31
32

In the areas that were evaluated, there were no deficiencies cited.

LPA discussed the requirements of AB 633 with the Director and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

A copy of this report was provided to the facility at the conclusion of the inspection.

NOTICE OF SITE VISIT WAS ISSUED. DIRECTOR WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3