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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408003
Report Date: 10/28/2021
Date Signed: 10/28/2021 02:35:01 PM

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 ACADEMYFACILITY NUMBER:
434408003
ADMINISTRATOR:KEITH HADENFACILITY TYPE:
850
ADDRESS:878 LAKEWOOD DRIVETELEPHONE:
(408) 737-7022
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:32CENSUS: 4DATE:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Keith HadenTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Mel Matos met with Keith Haden, Owner/Director, for an unannounced Required - 1 Year inspection. LPA toured the indoor and outdoor areas of the Facility with Keith during today's inspection. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus, current Fire Drill Log, and Activity Schedule. Days and hours of operation are Monday through Friday 7:00 AM to 6:00 PM. The facility is licensed to serve a maximum of thirty two preschool children ages two to six years old in the Orange, Blue, Red, and Yellow Rooms.

Keith 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.

LPA reviewed five children's and one staff file (director) during today's inspection. Each child's file reviewed contains the Information and Emergency Information form (LIC 700) and all required licensing forms. The director's file reviewed contain the required transcripts/verification of experience/immunization records, and Health Screening Report. Keith has current certificates of completion of the Mandated Reporter Training for Child Care Workers on file. Keith has current CPR and First Aid certifications on file. Keith understands 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 (field trips).



LPA observed that the teacher/child ratio was in compliance during today's inspection. LPA observed four napping preschool children in the Orange Room during today's inspection. Keith understands the conditions, limitations, and capacity specifications of the Facility license. Keith understands that children shall be visually supervised at all times. Any child(ren) who exhibit symptoms of illness including, but not limited to, fever or vomiting, are not accepted in care. Any child(ren) who become ill during the day, shall be isolated in the director’s office area.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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: 10/28/2021
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LPA observed that the Facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. Keith states that he cleans the Facility Monday through Friday in the evenings. Keith understands that the Facility must be kept free of flies and other insects & rodents. LPA observed that all furniture and equipment is in good condition and safe for the children. Drinking water is readily available for the children in the Facility and in the outdoor playground area via water bottles/drinking fountains/disposable cups. 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 needed. Keith states that there are no weapons or firearms on the premises. The Facility has functioning carbon monoxide detectors indoors.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. The Facility only provides snacks to the children. Parents provide lunches for the children. The Facility has trash cans with tight fitting lids for solid waste in each Room. Cleaning supplies are inaccessible to the children and stored in high cabinets inaccessible to children. LPA observed a complete First Aid kit, including touch less thermometer, in the Facility.

The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. Shade is provided by trees and building overhang in the playground. There is sufficient resilient materials (wood chips) in the outdoor playground area. LPA did not observe any bodies of water. Keith states that the Facility does not provide transportation.

This facility is not providing Incidental Medical Services – IMS at this time. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. Keith states that the Facility does not administer any medication.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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


Exit interview conducted and report was reviewed with the licensee/director, Keith Haden.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC809 (FAS) - (06/04)
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