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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410620
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:15:31 PM


Document Has Been Signed on 02/23/2023 03:15 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:LITTLE TREE PLAYSCHOOL, THEFACILITY NUMBER:
434410620
ADMINISTRATOR:WRIGHT, RACHELEFACILITY TYPE:
850
ADDRESS:7275 SANTA TERESA BLVD.TELEPHONE:
(408) 972-9200
CITY:SAN JOSESTATE: CAZIP CODE:
95139
CAPACITY:30CENSUS: 18DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Sarah Gavia and Cristina BeaucheminTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Janette Cruz met with Sarah Gavia, Lead Teacher and Cristina Beauchemin, Pastor for New Creation Lutheran Church / teacher aide, for an unannounced Required- 1 Year inspection. LPA toured the indoor and outdoor areas of the facility 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), and Activity Schedule. Days and hours of operations are Monday through Friday 7:00 AM to 6:00 PM. The facility has active waivers on file : shared playground for preschool/toddler option, shared bathroom for preschool/toddler option and commingling of preschool/toddler option on the hours of 7AM-8AM and 5PM-6PM.

LPA reviewed children's files and staff files (director, two teachers/ teacher aide) during today's inspection. Each child's file reviewed contains the Information and Emergency Information form (LIC 700) and required licensing forms. All staff files reviewed contain the required transcripts/verification of experience, and Health Screening Report. LPA reviewed current certificates of completion of the Mandated Reporter Training for Child Care Workers and current CPR and First Aid certifications for staff on file. Lead Teacher understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during outdoor activities. Sign in and sign out sheets via electronic app are in compliance.



LPA observed that the teacher/child ratio was in compliance during today's inspection. Present during the inspection were 14 preschool children, 4 toddlers and 3 staff. Lead Teacher understands the conditions, limitations, and capacity specifications of the Facility license. Lead Teacher 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 facility's office.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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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: LITTLE TREE PLAYSCHOOL, THE
FACILITY NUMBER: 434410620
VISIT DATE: 02/23/2023
NARRATIVE
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LPA observed that the Facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. Lead Teacher understands that the facility must be kept free of insects & rodents. LPA observed that all furniture and equipment are 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 labeled with each child's name. Staff and children's bathrooms are clean, sanitary, and in working order. Lead Teacher 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, free of rodents and other vermin. There is also a hot and cold running water, refrigerator and microwave on the premises. Lunch is optional, prepared at the facility or brought from home. The facility provides snacks to the children in care. Menu was posted. The kitchen used to prepare snacks was observed to be clean and sanitary. The Facility has trash cans with tight fitting lids for solid waste in the classroom. Cleaning supplies are inaccessible to the children and stored in locked cabinets. LPA observed first aid kit available in the classrooms.

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 rest areas are provided by shade canopies. There is sufficient resilient materials (woodchips, artificial grass) on the outdoor playground area. LPA observed a locked storage shed. There are chickens in a chicken coop observed at the outdoor area. LPA did not observe any bodies of water. Director states that the Facility does not provide transportation.

Director 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.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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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: LITTLE TREE PLAYSCHOOL, THE
FACILITY NUMBER: 434410620
VISIT DATE: 02/23/2023
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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

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 Sarah Gavia and Cristina Beauchemin. Deficiencies were cited during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/23/2023 03:15 PM - 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: LITTLE TREE PLAYSCHOOL, THE
FACILITY NUMBER: 434410620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. facility has not done a lead testing for its drinking water and documentation is not available on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2023
Plan of Correction
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Licensee will review and submit all requirements for Lead Testing for Child Care Centers by POC due date.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above. Staff S2 does not have a pertussis immunization on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2023
Plan of Correction
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Licensee will submit a pertussis immunization record for S2 by POC due date.
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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 02/23/2023 03:15 PM - 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: LITTLE TREE PLAYSCHOOL, THE
FACILITY NUMBER: 434410620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. All staff present during today's inspection (S2, S3, S4) and Director S1 did not have a current Mandated Training Certificate on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2023
Plan of Correction
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Licensee will submit a Mandated Reporter Training Certificate for the four staff by POC due date.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) 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 medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above, Child enrolled, C4, does not havee LIC701 Physician's Report on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2023
Plan of Correction
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Licensee will submit LIC701Physician's Report for child enrolled C4 by POC due date.
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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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