434407962-4-24-2025-07-CC-JBER-DG2REV-20250424125806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434407962
Report Date: 04/24/2025
Date Signed: 04/24/2025 12:58:44 PM

Document Has Been Signed on 04/24/2025 12:58 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	LOS GATOS ACADEMY PRESCHOOL		FACILITY NUMBER:	434407962
ADMINISTRATOR/ DIRECTOR:	JENNIFER SMOYLANITSKY		FACILITY TYPE:	850
ADDRESS:	16837 PLACER OAKS ROAD		TELEPHONE:	(408) 242-9342
CITY:	LOS GATOS	STATE: CA	ZIP CODE:	95032
CAPACITY: 34	TOTAL ENROLLED CHILDREN: 34	CENSUS: 19	DATE:	04/24/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:40 AM
MET WITH:	Kyah Hossay		TIME VISIT/ INSPECTION COMPLETED:	01:15 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	Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Facility Representative, Kyah Hossay, for an unannounced Random/Annual Inspection. LPA was granted access to the facility by the staff and toured both indoors and outdoors during the inspection. Upon arrival, there were 19 children (preschool-age) and 3 staff present, which is compliant with the facility license capacity requirements. LPA observed all required postings near the entrance to the facility. Hours of operation for the facility are Monday – Friday, 08:30AM-05:30PM. There are no active waivers. Facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. All staff present had criminal record clearance and were associated to the roster on Guardian. LPA reviewed sign-in/out sheets and fire/disaster drill log during today’s inspection. Sign-in/out was observed to be completed with full legal signature and time of day. The last fire/disaster drill was conducted on 10/08/2024, which is not compliant with the six month requirement for facilities. LPA observed a fully charged 3A40BC fire extinguisher last serviced 08/22/2024, which is compliant with state fire marshal regulations. LPA observed a fully functioning smoke detector system. A carbon monoxide detector could not be located during today's visit. Continued on Page 2

Gladys Kuizon	TELEPHONE: (510) 566-5850
Jennifer Beehler	TELEPHONE: (408) 324-2148
	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

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 11

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 11

Document Has Been Signed on 04/24/2025 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LOS GATOS ACADEMY PRESCHOOL	FACILITY NUMBER: 434407962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

101174(d)

Disaster and Mass Casualty Plan

(d) Disaster drills shall be conducted at least every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as last Fire/Disaster drill log was conducted more than 6 months from the last Fire/Disaster Drill which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2025
	Plan of Correction
1 2 3 4	Facility to complete a Fire/Diaster Drill and log the activity. Director to send photographic proof to LPA. Director to provide a written plan how to address this in the future so Fire/Disaster Drills are conducted at least every 6 months and logged in accordance to written directives.

Type B

Section Cited

CCR

101238.2(d)(1)

Outdoor Activity Space

(d) The surface of the outdoor activity space shall be maintained: (1) In a safe condition for the activities planned. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above as two side panels on the upper deck of the large play structure were loose. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Facility to secure and strengthen the panels as necessary to insure children are safe while on the top deck of the play structure. Director to provide a video showing the panels are stable and secure. Director to provide a written plan to address regular maintenance and review of safety standards for the play structure to insure outdoor activity space is always in compliance.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Gladys Kuizon	TELEPHONE: (510) 566-5850
Jennifer Beehler	TELEPHONE: (408) 324-2148
	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

Page: 3 of 11

Document Has Been Signed on 04/24/2025 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LOS GATOS ACADEMY PRESCHOOL	FACILITY NUMBER: 434407962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	All staff to complete the Mandated Reporter training that satisfies the requirement of AB1207 - Child Care Provider. Director to provide copies of the certificate of completion to LPA along with a written plan how the facility will track required training to insure training is completed every two years in accordance with written directives.

Type B

Section Cited

CCR

101217(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above in 4 out of 4 staff files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Facility to create a written plan on how files can be accessed when the Director is not on site. Director to provide copies of complete staff files for all staff including the Director to LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Gladys Kuizon	TELEPHONE: (510) 566-5850
Jennifer Beehler	TELEPHONE: (408) 324-2148
	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

Page: 4 of 11

Document Has Been Signed on 04/24/2025 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LOS GATOS ACADEMY PRESCHOOL	FACILITY NUMBER: 434407962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1597.16(a)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above as the facility has not had their water faculties tested by 01/01/2023 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2025
	Plan of Correction
1 2 3 4	Facility to schedule the water testing date and notify the Department of the scheduled day by 04/25/2025, along with securing bottled water from an outside source to provide to children until testing is completed and results meet lead exceedance regulations. Director to submit a written plan to address future testing so that compliance is maintained every 5 years. Director to provide LPA with a copy of the lead testing results by no later than 05/25/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Gladys Kuizon	TELEPHONE: (510) 566-5850
Jennifer Beehler	TELEPHONE: (408) 324-2148
	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

Page: 6 of 11

Document Has Been Signed on 04/24/2025 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LOS GATOS ACADEMY PRESCHOOL	FACILITY NUMBER: 434407962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1596.954

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above in 1 out of 1 times which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Facility to install a CO2 detector in accordance with manufacturing standards and email photographic proof of installation to LPA.

Type B

Section Cited

CCR

101238(g)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above as the door to the garage could not be closed and it stores paints and hazardous chemicals which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Door to be fixed so that it can be closed and locked or hazardous chemicals need to be moved to insure they are inaccessible to children in care. Director to provide a written plan detailing how facility will address keeping hazardous materials inaccessible from children in care at all times.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Gladys Kuizon	TELEPHONE: (510) 566-5850
Jennifer Beehler	TELEPHONE: (408) 324-2148
	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

Page: 7 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LOS GATOS ACADEMY PRESCHOOL	FACILITY NUMBER: 434407962
	VISIT DATE: 04/24/2025

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

Facility Representative states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Indoor areas of the facility were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom, not utilized by the children, which an isolated child can use if necessary. The Facility Representative states a working landline is designated for the facility. Cleaning and maintenance for the facility is conducted daily by staff such as sweeping, mopping and wiping down surfaces. A deep clean is conducted quarterly during in-service days where staff are in attendance without children and sanitize all toys, mats and any thing else that requires a deep cleaning. The Facility Representative states that there are no weapons or firearms on the premises.

The outdoor area of the facility was inspected and observed to be fenced in. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (rubber padding and tanbark) to absorb falls. LPA observed the top deck of the large play structure to have loose panels on both sides. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by trees and umbrella.

Food is provided by the facility and is stored, prepared, and served in a safe and healthful manner to the children. Facility offers full day program and provides (midmorning snack, midafternoon snack, and lunch) to children. Menu is in writing and posted at least one week in advance, accessible to authorized representatives. The kitchen and storage area is clean and free of litter and rubbish. Equipment necessary for the storage, preparation and service of food is well maintained, clean, and sanitized after each use. Drinking water is readily available for children in the facility via water dispenser in the kitchen refrigerator and water bottles from home labeled with the children’s names.

Continued on Page 3

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Jennifer Beehler	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

Page: 8 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LOS GATOS ACADEMY PRESCHOOL	FACILITY NUMBER: 434407962
	VISIT DATE: 04/24/2025

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

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). The facility has not completed the Lead testing in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

5 children’s files (preschool-age) were reviewed during today’s inspection for the following records: Physician’s Report (LIC701), Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Signed Admission Agreement, and Immunization Records (PM286). LPA observed files to be complete.

0 staff files were reviewed for the following records: Transcripts/Verification of Experience, Health Screening Report (LIC503), Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, Tuberculosis (TB) Clearance, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). Staff files were inaccessible for review, so these documents could not be verified during the visit. LPA could not verify if there was a current CPR training for any staff. Mandated Reporter was expired in 2024. LPA reminded Facility Representative that the Mandated Reporter Training must be renewed by all staff every 2 years.

The Facility representative understands that the site director shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. LPA reminded Facility Representative that there shall be at least one person with valid CPR and First-Aid certifications on site at all times or present during off site activities, such as field trips.

As a result of today's inspection, deficiencies have been cited. More information provided on the attached LIC809-D pages.

Continued on Page 4

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Jennifer Beehler	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

Page: 9 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LOS GATOS ACADEMY PRESCHOOL	FACILITY NUMBER: 434407962
	VISIT DATE: 04/24/2025

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

LPA informed Facility Representative, Kyah Hossay that this report dated 04/24/2025 documents 1-Type A citation and must be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care. Licensee to provide a copy of this licensing report dated 04/24/2025 that documents this Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the Facility Representative, Kyah Hossay.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Jennifer Beehler	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

Page: 10 of 11

Document Has Been Signed on 04/24/2025 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LOS GATOS ACADEMY PRESCHOOL	FACILITY NUMBER: 434407962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

101229(a)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above as two children were using the restroom without visual supervision which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Director to provide a written plan addressing visual supervision during outdoor play time to address bathroom breaks if only two staff people are present to insure all children in care are visually supervised at all times, in accordance with written directives.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Gladys Kuizon	TELEPHONE: (510) 566-5850
Jennifer Beehler	TELEPHONE: (408) 324-2148
	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

Page: 11 of 11