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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408734
Report Date: 06/26/2024
Date Signed: 06/26/2024 11:45:50 AM


Document Has Been Signed on 06/26/2024 11:45 AM - 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:MARSHALL LANE PRESCHOOLFACILITY NUMBER:
434408734
ADMINISTRATOR:HEATHER ELSTONFACILITY TYPE:
850
ADDRESS:14114 MARILYN LANETELEPHONE:
(408) 364-4259
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:48CENSUS: 24DATE:
06/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Donna JacksonTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management-Incident inspection. LPA met with Salima Jasmine and Donna Jackson, CDC Specialist, and explained the reason for the inspection. Preschool Supervisor, Tiffany Bui, arrived shortly after. The purpose of this inspection is to review a self-report incident that occurred on 06/21/2024 involving absence of supervision. Incident was self-reported to the San Jose Regional Office on 06/24/2024.

During today's inspection, LPA interviewed staff and inspected the physical plant. Children were transitioning from outside to inside. A child was outside after the room had transitioned inside. The bathroom door and the classroom door was closed. Staff had conducted another head count inside and observed that a child was missing. Staff stated that child was outside of the room by the window. The staff brought the child inside.

Donna stated that they conducted a staff meeting on 06/24/2024 regarding transitions and supervision. Preschool Supervisor will be conducting another team meeting the week of July 1st, 2024 regarding supervision.

As a result of this inspection, a Type A citation was issued. Exit interview conducted and report was reviewed with Tiffany Bui, Preschool Supervisor. A notice of site visit has been issued and must remain posted for 30 days.

LPA Samantha Yip informed Preschool Supervisor, Tiffany Bui, that this report dated 06/26/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Preschool Supervisor, Tiffany Bui, to provide a copy of this licensing report dated 06/26/2024 that documents any Type A citation(s) 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.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/26/2024 11:45 AM - 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: MARSHALL LANE PRESCHOOL
FACILITY NUMBER: 434408734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time...
This requirement is not met as evidenced by:
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By POC 06/27/2024, the center will submit a written plan on how they will ensure children are supervised at all time.
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Based on interview, a child was outside after the room had transitioned from outside to inside. A staff brought the child back inside after a head count was completed. This poses an immediate health and safety risk to children in care.
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The center will also submit notes from staff training and list of staff who attended training.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
LIC809 (FAS) - (06/04)
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