434412148-5-9-2023-07-CC-PHEZ-CRNRE2-20230509125648

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434412148
Report Date: 05/09/2023
Date Signed: 05/09/2023 12:57:24 PM

Document Has Been Signed on 05/09/2023 12:57 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	EVERGREEN MONTESSORI SCHOOL-YB		FACILITY NUMBER:	434412148
ADMINISTRATOR:	VARSHA KUMAR		FACILITY TYPE:	850
ADDRESS:	3403 YERBA BUENA ROAD BLDG D		TELEPHONE:	(408) 238-7001
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY: 57	TOTAL ENROLLED CHILDREN: 57	CENSUS: 44	DATE:	05/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Varsha Kumar		TIME COMPLETED:	01:09 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 at the facility today. Upon arrival, LPA observed forty eight (44) preschool and toddler age children and at least fourteen (12) staff engaging in daily activities and met with Ms.Varsha Kumar, Director. LPA toured the facility inside and out and observed required postings including but not limited to; the License to Operate, Emergency Disaster Plan (LIC 610) and Notification of Parents Rights (PUB 393). Days and hours of operation are Monday through Friday 7:30am to 6:00pm. The Director stated that the summer program has the same days and hours of operation. The facility is licensed to serve a maximum of fifty seven (57) children ages two (2) years old to entry to First Grade in classrooms #1 and #2, with an option to serve up to thirteen (13) children ages 18 months to 36 months in classroom #3. LPA observed the facility to be within ratio and supervision requirements at the time of the inspection and confirmed that Toddler teachers maintain infant / toddler educational units. LPA observed that the facility is operating within the terms of the license and is in compliance with the approved fire clearance capacity. The facility was toured inside and out and was observed to be clean, safe, sanitary, and in good repair. Disinfectants, cleaning solutions, and all other items that are dangerous to children were observed to be securely stored and inaccessible. Indoor and outdoor activity spaces were observed as properly equipped with age appropriate toys and supplies that are in safe condition. LPA observed outdoor play areas are physically separate and that toddler and preschool age groups are not commingled. Storage containers for waste have tight fitting covers, the restrooms were observed to be clean and functional, and floors and carpeting are free from hazard and obstruction. The facility serves snacks and meals to children. The Director stated that parents are informed what foods may be served via posted menus and an online website. The Director stated that all staff are aware of food allergies or dietary restrictions, which are outlined in children's files. LPA discussed staff protocols upon serving food such as; visual observation of all foods and maintaining appropriate temperatures prior to serving. LPA observed mats, pillows, and blankets for napping and changing tables within arms reach of a sink. LPA reminded the Director that changing tables should be made of a material that can be disinfected in between uses. The Director stated that during napping time children's mats are appropriately spaced throughout the room, allowing for a walkway in between mats. Linens are washed regularly at the facility. LPA observed half doors and doors securing classrooms and certain areas within classrooms. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 05/19/2023):*

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: EVERGREEN MONTESSORI SCHOOL-YB	FACILITY NUMBER: 434412148
	VISIT DATE: 05/09/2023

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 05/09/2023):
LPA toured the outdoor play area, which was observed to be safe and equipped with age appropriate toys, structures, and equipment. There is secure perimeter fencing and the area is physically separate from all other outdoor activity areas. LPA observed that there is sufficient absorbent materials, drinking water available for children via pitchers, cups, and water fountains, and there is also covering for shade provided by trees and the angle of the building overhand. *. LPA and the Director discussed transition protocol, including direct supervision of children at all times.

No weapons are stored on site and no bodies of water are on the premises. LPA observed fire extinguishers, smoke detectors, carbon monoxide detectors, a central alarm system, and complete first aid kits throughout the facility. Emergency disaster drills are performed as required, last of which was done in 2/22/2023. The facility also maintains written logs of emergency disaster drills and procedures. LPA reviewed a random sample of children's records and observed that there is a separate, complete, and current record for each child enrolled in the center. LPA observed that each child record reviewed maintained a valid health screening report, required immunization records, and emergency contact information. The facility maintains a written sign in and out sheet at this time, that is updated throughout the day, containing full signatures from responsible parties. The facility maintains an updated roster of children enrolled in the program. The last fire safety inspection conducted by the local fire authority was performed in the past 12 months in which detectors, alarm systems, and fire extinguishers were serviced. LPA reminded the Director that all fire safety items and equipment should be maintained at least every 12 months.

*LPA and the Director discussed children's outside activity time based on weather (heat during summer months, air quality etc.), hydration, supervision, and safety items.

A random sample of administration and staff records were reviewed and all teachers and staff maintain valid background clearances. LPA reviewed a random sample of teacher files and observed at least one staff on site maintains valid CPR / First aid certification which expires in 9/17/2024. The Director stated that she is aware that there must be at least one staff with current CPR/ First Aid training at all times. The facility does not provide transportation to the children. LPA and the Director discussed emergency disaster drills and preparedness, emergency lock-down procedures, children's personal rights including no corporal punishment, forms of discipline, AB 633, healthy beverages in child care, recent updates to the child seat belt law, payment of licensing fees, and surveillance systems in common areas.
REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 05/09/2023):

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: EVERGREEN MONTESSORI SCHOOL-YB	FACILITY NUMBER: 434412148
	VISIT DATE: 05/09/2023

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 05/09/2023):

The Director has been referred to the department website for Licensing forms, resources, and updates: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing

A review of staff records today indicate that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also discussed and reviewed immunization including Measles, Pertussis, and Influenza. LPA also reminded Licensee 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. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

LPA advised the Director of the immunization requirement regarding Senate Bill 792 (pertussis, measles, and flu vaccines) for ALL STAFF THAT WORK DIRECTLY WITH CHILDREN. LPA advised the Director on information regarding lead in drinking water and the affects on children and families, and the required "Mandated Reporter" training that all staff will be required to complete starting January 1, 2018 per AB 1207. LPA referred the Director to the Department website: www.ccld.ca.gov for additional information on the online training and applicable updates as of 2019.
https://mandatedreporterca.com/

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 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

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: EVERGREEN MONTESSORI SCHOOL-YB	FACILITY NUMBER: 434412148
	VISIT DATE: 05/09/2023

NARRATIVE

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Should there ever be 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 An exit interview was conducted, and Plan of Corrections were reviewed and developed with the licensee. A copy of this report was discussed and left with the Licensee, Varsha Kumar, 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.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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