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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408922
Report Date: 09/25/2019
Date Signed: 09/25/2019 03:46:42 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:NIMITZ CDC- PRESCHOOL PROGRAMFACILITY NUMBER:
434408922
ADMINISTRATOR:KINOHI, NOREENFACILITY TYPE:
850
ADDRESS:545 CHEYENNE DRIVETELEPHONE:
(408) 736-6176
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:24CENSUS: 9DATE:
09/25/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Briana HussTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuoc Doan conducted an unannounced Annual inspection of the Preschool Program. LPA met with Director Briana Huss and informed her the purpose of the visit. Facility's License, Notification of Parents’ Right Poster, Child Car Seat Law, LIC613A Personal Rights, and Activity Schedule were observed to be posted. The Preschool Program operates Monday through Friday from 09:00 AM to 12:00 PM in Classroom #22. Facility also has a School-Age Program that uses Classroom #22 each day after the Preschool Program ends.

The Preschool operates on a functioning school site, Nimitz Elementary School. LPA inspected the building inside and out. Facility was operating in compliance with teacher and adult to children ratio requirement. Classroom #22, two restrooms, food preparation area and Kitchen, and office area were inspected. There were no bodies of water observed. Director stated that facility do not possess nor store any weapons on the premises. Furniture and equipment were in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, poisons, and other items that are dangerous to children were stored inaccessible to children. Restrooms were in operating conditions. Facility holds a waiver for the preschool children to use the Elementary School's TK Playground, which is enclosed by fencing. Play equipment was in good condition and areas under high climbing equipment have resilient material to absorb falls. Dinking water was readily available to children.

Facility provides AM snack to the Preschoolers. Snack menu was posted. Snacks are stored and prepared in the Kitchen in Classroom #21. LPA observed that foods and beverages were kept protected against contamination and spoilage. Food preparation area and storage were observed to be clean, free of litter, rubbish, and rodents/vermin. Trash cans for solid waste had tight-fitting covers on, and were in good repair.
First Aid Kit was inspected. Fire extinguishers were last serviced on 07/2019. Smoke detectors were observed. Carbon Monoxide detector was tested and proved to be functioning. The first Fire and Disaster drills for this academic year are scheduled to be practiced on 09/27/19.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2019
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: NIMITZ CDC- PRESCHOOL PROGRAM
FACILITY NUMBER: 434408922
VISIT DATE: 09/25/2019
NARRATIVE
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LPA reviewed sign in and out record. A sampling of children and staff files was taken for review. Children records reviewed include Admission Agreement, Identification and Emergency Contact Information, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, Medical Assessment, and Immunization. Staff records reviewed include Criminal Record and Child Abuse Index Clearance, Health Screening Report with TB Clearance, Immunization (Measles and Pertussis), and required Training. LPA reminded Director that the AB1207 Mandated Reporter Training needs to be renewed every two years. There was at least one person with current certification in Pediatric CPR and First Aid present.

Facility's Incidental Medical Services – IMS pilocy was discussed. Per Director, currently facility does not have children in care who requires IMS. 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 Child Care Center and the ADA, available at: http://www.ada.gov/childqanda.htm.

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 to 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 to 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 [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, etc. Beginning January 1, 2019 AB2370 requires licensed the center to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. A copy of the “Lead Poisoning Facts Information Flyer” was provided.

In the areas that were evaluated, regulatory violations were observed at the time of the visit. Exit interview was conducted, where this report, the violations, plan of corrections, and appeal rights were reviewed with Director.

A NOTICE OF SITE VISIT WAS ISSUE 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 KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2019
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: NIMITZ CDC- PRESCHOOL PROGRAM
FACILITY NUMBER: 434408922
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2019
Section Cited

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CHILD'S MEDICAL ASSESSMENT. Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child.

This requirement is not met as evidenced by:
Per LPA's review of files, facility failed to
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obtain a medical assessment of Child 1 and 2. They have been enrolled for more than 30 days. This poses a potential risk to the health and safety of children in care.
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Type B
10/04/2019
Section Cited

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IMMUNIZATION. The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled

This requirement is not met as evidenced by:
Per LPA's review of files, facility failed to
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document Child 1's immunization record. This poses a potential risk to the health and safety of children in care.
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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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3