434408003-6-1-2021-07-CC-SCOS-C3KMRU-20210601095056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434408003
Report Date: 05/26/2021
Date Signed: 06/01/2021 09:51:44 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:	SMALL WORLD ACADEMY		FACILITY NUMBER:	434408003
ADMINISTRATOR:	KEITH HADEN		FACILITY TYPE:	850
ADDRESS:	878 LAKEWOOD DRIVE		TELEPHONE:	4087377022
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94089
CAPACITY:	24	CENSUS: 0	DATE:	05/26/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	10:42 AM
MET WITH:	Keith Haden		TIME COMPLETED:	10:43 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	Due to COVID-19 and DPH (Department of Public Health) guidelines of social distancing, This LIC809 Facility Evaluation Report will be emailed to the facility. Facility’s reply to the email will serve as acknowledgement that the report was received. Licensing Program Analysts (LPA) Stephanie Collins conducted a Tele conference with director Keith Haden at the facility. The tele Conference is in response to Licensee’s request for an increase in the capacity of the Preschool License from 24 to 32 preschool children. Fire Clearance granted on 5/20/2020 The Preschool was previously measured on 11/18/2004 with a maximum capacity of 38 preschool children. Director states nothing major has change. Case carry licensing program analysts completed a facility inspection on 11/12/2019 and reports no structural changes observed. Per measurements from 07/10/04: *INDOOR MEASUREMENTS ARE AS FOLLOW:* Red Room 42.000 X 11.913 = 500.346 minus 60.907 (encumbered space) = 439.439 Yellow Room 20.166 X 18.249 = 368.009 minus 27. 135 (encumbered space) = 340.874 Blue Room 21.00 X 15.830 = 332.430 minute 23.443 (encumbered space) 308.987 Orange Room 21.00 x 12.830= 269.430 TOTAL PRESCHOOL INDOOR ACTIVITY SPACE: 1358.730 sq. ft divided by 35 = 38 Preschool Children *There are 5 toilets (75) and 5 sinks (75) for the children*

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Stephanie Collins	TELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

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 2

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: SMALL WORLD ACADEMY	FACILITY NUMBER: 434408003
	VISIT DATE: 05/26/2021

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

Playground
46.249 x 23.083 = 1067.565
82.249 x 74.00 = 6086.426
½(29.249) x 66.00 = 965.217

TOTAL PRESCHOOL OUTDOOR SPACE: 8119.208 sq.ft. divided by 75 + 108 children
previous measured taken on 11/18/2004

Facility was informed that Facility’s file will be submitted to Licensing Management for final approval.
Supportive documents requested and submitted:
Emergency Disaster Plan-LIC 610
Photos of Facility indoor active space

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Stephanie Collins	TELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2