434408015-5-18-2022-07-CC-PHEZ-CEJQE7-20220518120552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434408015
Report Date: 05/18/2022
Date Signed: 05/18/2022 12:06:23 PM

Document Has Been Signed on 05/18/2022 12:06 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	ANDERSON VILLAGE STATE PRESCHOOL		FACILITY NUMBER:	434408015
ADMINISTRATOR:	JEANETTE ESCOBAR		FACILITY TYPE:	850
ADDRESS:	4000 RHODA DRIVE		TELEPHONE:	(408) 874-3100
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	61	CENSUS: 25	DATE:	05/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Jeanette Escobar		TIME COMPLETED:	12:15 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) Pete Hernandez conducted an unannounced, Required 1 Year inspection, met with the Preschool Program Director, Jeanette Escobar and Site Administrator Director Amarjit Kaur, and explained the nature of today's inspection. The following ratios in the rooms currently used during time of inspection: There is one Waiver on file and posted: 1) Inclusion Exception. 2) Share Playground Waiver. . Room P2: 1 Teacher and 1 Aid / 12 Children Room P1: 1 Teacher and 1 Aid / 13 Children Room A3: Currently not in use Room A4: Currently not in use The facility was in compliance with teacher/ child ratios, children were not left unattended and were constantly under the direct visual supervision of a staff person. LPA noted the staff and children were interacting in various activities. Normal Business hours Monday - Friday 8:00 AM to 2:35 PM. LPA completed a physical plant inspection touring the building inside and out. No bodies of water were found. Director stated that there are no weapons stored in the facility. Disinfectants, cleaning solutions, poisons, and other items that are dangerous to infants were locked up and inaccessible. Furniture and equipment was in good condition, free of sharp, loose, or pointed parts. Continued on Page #2. Report dated 5/18/2022

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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: ANDERSON VILLAGE STATE PRESCHOOL	FACILITY NUMBER: 434408015
	VISIT DATE: 05/18/2022

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 has age appropriate furniture and equipment. No baby walkers or bouncers were witnessed during the inspection. All storage containers for solid waste had tight fitting covers and were in good repair. Facility was free of flies, other insects, and rodents. Facility has adequate indoor activity space for children that is physically separate from space used by the preschool child care center. Bottles, dishes, and containers of food brought by the child's authorized representative are labeled with the child's name and current date. Facility has at least one functioning carbon monoxide detector that meets statutory requirements. Facility has adequate outdoor activity space and play equipment that is maintained in a safe condition and is free of hazards. Food is provided from the elementary school cafeteria.

The Facility had working Fire Extinguishers, smoke alarms and carbon monoxide detectors. The emergency drill log was current and the last entry was on 4/15/2022.

The outdoor activity area is surrounded by appropriate fencing. The play structure and equipment outside were age appropriate in good condition. Areas around play structure were cushioned with resilient materials. Shaded rest areas are provided by canopy. LPA did not observe any bodies of water.

All Staff were fingerprinted and associated to the facility. LPA reminded 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. For an initial violation, civil penalty amounts to $100.00 per person per day with a maximum of $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day with a maximum of $3000.00 per person. LPA also reviewed with Director the violations that would result in an immediate assessment of civil penalty in the amount of $500. Director is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.
Continued on

Page #3 of Report dated 5/18/2022

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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: ANDERSON VILLAGE STATE PRESCHOOL	FACILITY NUMBER: 434408015
	VISIT DATE: 05/18/2022

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

There was at least one Teacher with current certification in Pediatric CPR and First Aid present at the facility during inspection. Site Director's expires on 7/1//22. Children's Roster was reviewed, and a copy obtained.

LPA Hernandez reviewed the files of 4 Staff and 10 children. All or the required documentation was available in the file.

This facility provides Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A 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)/ (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

TYPE A language: SHOULD THERE EVER BE AN ISSUANCE of Type A citations today, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with the Licensee. A copy of this report was discussed and left with the Licensee, Amarjit Kaur, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3