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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412148
Report Date: 09/05/2024
Date Signed: 09/06/2024 09:06:42 AM

Document Has Been Signed on 09/06/2024 09:06 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:EVERGREEN MONTESSORI SCHOOL-YBFACILITY NUMBER:
434412148
ADMINISTRATOR/
DIRECTOR:		SANDHYA PANCHAGNIFACILITY TYPE:
850
ADDRESS:3403 YERBA BUENA ROAD BLDG DTELEPHONE:
(408) 238-7001
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 57TOTAL ENROLLED CHILDREN: 44CENSUS: 38DATE:
09/05/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:44 AM
MET WITH:Sandhya PanchagniTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 09/05/2024 at 8:44am, Licensing Program Analyst (LPA), Farida Raja, met with Director, Sandhya Panchagni and Owner, Sunita Prakash and for an unannounced Annual/Random inspection. The facility is licensed to serve children ages 2 years to entry into first grade in Rooms 1 & 2 and children in the toddler option ages 18 to 36 months in Room 3. LPA observed the required posted materials outside Room 1 and menus and lesson plans in each classroom. Days and hours of operation are Monday through Friday, 7:30 am to 6:00 pm.

LPA and Director toured the indoor and outdoor areas during today's inspection and observed the following ratios:
Room 1 (Birch)- 1 teacher : 6 children
Room 2 ( Maple)- 2 teachers: 8 children
Room 3 (Willow)- 2 teachers: 6 toddlers

Facility was in compliance with teacher to children ratio requirement. Classrooms, children's restrooms, staff restrooms, kitchen and office area were inspected. Children were observed engaged in individual mat activities under the visual supervision of teachers. Facility has central heating/cooling for comfort of children. Director states that there are no weapons or firearms on the premises. There is a working telephone at the facility (408-238-7001). Disinfectants and cleaning products were observed to be stored in high kitchen cabinets. Medicines are stored in a high cabinet in the office area. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. Indoor and outdoor activity spaces were observed to be properly equipped with age appropriate toys and supplies that are in safe condition. LPA observed solid waste containers with tight-fitting lids in the rooms. LPA observed appropriate changing tables that have raised sides and vinyl changing pads in Rooms 2 and 3 and changing tables within arms reach of a sink. LPA observed a trash can with tight fitting cover for the disposal of diapers. Napping equipment is appropriate. Restrooms and sinks for children were observed to be safe, sanitary, and in working condition. Staff has two separate bathrooms that can be utilized by sick children if needed.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 09/05/2024
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LPA observed fire extinguishers, working smoke and carbon monoxide detectors, and fire pull stations. Log shows that the last Fire Drill was conducted on 09/03/2024 which is compliant with the six-month requirement for facilities.

Drinking water is readily available for children in each room via individual water bottles and water pitcher and disposable cups.



Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5 years after the date of the first test.

Director stated that the building was built after 01/01/2010. LPA requested Director to submit proof showing building was constructed after January 1, 2010 to the Department by 09/12/2024.

Facility does provide meals and snacks to the children in care. Parents are allowed to provide meals and snacks as well. Menu was observed to be posted in the kitchen area and in each classroom. Director stated that the menu is also shared with parents on their website. Food and beverages were stored safely to prevent contamination and spoilage. Food storage and preparation areas were observed to be sanitary.

Outdoor playground and play equipment was inspected and observed to be fenced in and free of hazards. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient material around and under high climbing equipment and slides to absorb falls. Shaded rest areas are provided by pergola, trees, umbrellas and building overhang. There were no bodies of water observed. Drinking water is available outdoors through individual water bottles, water fountain, water pitcher and disposable cups. Director stated that playground adjacent to Room 1 is used by preschool children in Room 1 and playground behind Room 2 is used by Room 2 (preschool) and Room 3 (toddler component). Facility does not have a waiver for shared outdoor space. Director and owner stated that they will have children from Room 2 (preschool) use the preschool playground and children from Room 3 (toddler component) exclusively use the toddler playground. Director will submit a letter stating this.

Children sign in and out procedures and logs were reviewed. Children's roster was reviewed, and a copy was provided to the LPA. A random sample of seven (7) children’s files were reviewed.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
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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: 09/05/2024
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Each child's file contained the required forms. Facility is not conducting 15 minute nap checks on children under 24 months in the toddler component. LPA provided Director with PIN 20-24-CCP and reminded Director that as per Safe Sleep Regulations all children under 24 months need to be checked every 15 minute when asleep and a log needs to be maintained.

LPA discussed the safe sleep regulations with Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Three (3) staff files were reviewed. All teachers and staff maintain valid background clearances. All staff files reviewed contain the required transcripts/verification of experience. All staff files reviewed have current CPR and First Aid certification. Director understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips). All staff have the required immunization's against pertussis, measles and statement declining the influenza immunization. LPA observed required Mandated Reporter Training on file for all staff.

Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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 PIN 22-02-CCP. Facility has an approved IMS Plan on file with San Jose Regional Office. Any medications at the Facility are stored in the office inaccessible to children in care. Isolation of sick child was discussed, and Director explained that sick children will be isolated in the director's office and isolation equipment will be provided. A staff restroom which is off limits to other children is used if necessary. Child is always under visual supervision while in care of the facility.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
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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: 09/05/2024
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The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Facility does not provide transportation to children, but Director understands that children cannot be left alone, unattended in parked vehicles.

Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

One Type B deficiency was cited today on the attached LIC 809D page. Appeal rights provided. Exit interview conducted and report was reviewed with Director, Sandhya Panchagni.

NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
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Document Has Been Signed on 09/06/2024 09:06 AM - It Cannot Be Edited


Created By: Farida Raja On 09/05/2024 at 12:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: EVERGREEN MONTESSORI SCHOOL-YB
FACILITY NUMBER: 434412148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101429(a)(2)(C)(3)
Responsibility for Providing Care and Supervision for Infants
(C) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: (3) Time of each 15-minute check

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 for children in the toddler component under 24 months of age which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Director will conduct 15 minute nap checks for all children under 24 months in the toddler component and submit proof to LPA by POC due date of 09/19/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


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