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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412157
Report Date: 07/27/2022
Date Signed: 07/27/2022 02:01:48 PM


Document Has Been Signed on 07/27/2022 02:01 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:APPLETREE MONTESSORI SCHOOLFACILITY NUMBER:
434412157
ADMINISTRATOR:RENU JAYAFACILITY TYPE:
850
ADDRESS:653 WEST FREMONT AVENUETELEPHONE:
(650) 575-9147
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:40CENSUS: 0DATE:
07/27/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Renu JayaTIME COMPLETED:
02:15 PM
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 Licensing Program Analyst (LPA) Dung Mac and Licensing Program Manager (LPM) Mary Segura, conducted an unannounced case management inspection in response to a request for room and capacity change from 40 to 30. LPA and LPM met with Renu Jaya, Licensee/Director, and explained the purpose of today’s inspection. The facility will be relocated to Rooms 6,7 & 10 which are on the back of the Seventh-Day Adventist Church’s property.

The facility will operate Monday through Friday from 8:30:00AM to 6:00PM, serving children ages 2-6 years old. LPA and LPM toured and measured the indoor areas of the facility during today's inspection.

INDOOR ACTIVITY SPACE:

ROOM 6: (22.750 x 8.667 + 22.750 x 11.167) minus
(1/2 5.000 x 3.667 + 4.667 x 10 + 2.083 x 3.083 + 4.667 x 10)
= 451.224 - 99.762 = 351.462

ROOM 7: (22.750 x 19.500) minus (1.750 x 2.667 + 1.667 x 2.333)
= 443.625 - 8.556 = 435.069

TOTAL INDOOR SPACE: 886.531 sq. ft. divided by 35 = 22 children

There is a labeled women's rest room that has two stalls with a toilet in each stall and two sinks. The room labeled Men's room has one toilet and one sink and will be used as the staff/sick child restroom. Children sinks have both hot and cold running water and were measured 115 degrees. There is a trash can with tight-fitting lid located in Room 7. LPA and LPA did not observe a trash can with tight-fitting lid is in Room 6. Sick children will be isolated in the director’s office and isolation equipment will be provided.

Report To Be Continued on Page #2
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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: APPLETREE MONTESSORI SCHOOL
FACILITY NUMBER: 434412157
VISIT DATE: 07/27/2022
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There are 37 cubbies, 28 chairs, 10 tables, and 10 mats. There is adequate equipment, supplies, and toys for the children. Drinking water will be provided indoors via water dispensers with paper cups/individual bottles. Smoke/carbon monoxide detectors and appropriate lighting were observed in both classrooms. Facility is not providing transportation.

OUTDOOR MEASUREMENTS:
63.83 X 38.415 = 2452.029

TOTAL YARD SPACE:2452.029 sq. ft. divided by 75 = 32 children
(measurements were previously measured by LPA Ikkanda on 12/14/2010)

LPA and LPM observed that the play yard is enclosed by the appropriate fencing. Shade is provided by canopy (soon) and trees. Half the yard has wood chips for the play structure; however, there were not sufficient resilient material to cover the yard and areas around and under the play structure. The artificial grass on the another half yard was ripped which might cause tripping hazards. Sand box was not covered. One of water fountain was not working. LPM And LPA observed the jutting nails on the wood bar.

Facility does not have the director's file on site for review. Site Director's certificate of Mandated Reporter Training was expired 6/5/2021. A staff is working at the facility, however, staff was not associated to the facility.

Facility is not providing Incidental Medical Services at this time .Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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

Report To Be Continued on Page #3
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: APPLETREE MONTESSORI SCHOOL
FACILITY NUMBER: 434412157
VISIT DATE: 07/27/2022
NARRATIVE
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with Renu Jaya, Licensee/Director. LPA and LPM advised Renu that a license for 22 children will be submitted to Licensing Management for the final stage of approval upon receiving the following items:
1) Updated application (LIC 200A) received today.
2) Updated Designation of Facility Responsibility (LIC 308) received today
3) Updated Lease Agreement
5) Updated sketch with the classroom numbers (LIC 999)
4) A trash can with tight-fitting lid in Room 6
5) A cot/mat for sick child in the director office
6) Photos of all classrooms having the room number signs
7) Photo of men restroom was labelled as staff/sick child restroom
8) Copy of renewal Mandated Reporter Training AB1207 for licensee
9) Photos of jutting nails were removed
10) Photo of covered sandbox
11) Photos of sufficient resilient materials and absence of any tripping hazards
12) Photos of artificial grass was removed or replaced
13) Photo of working water fountain or removal

Note: fire clearance with updated capacity and room numbers needs to be received before the room changes can be approved.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/27/2022 02:01 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: APPLETREE MONTESSORI SCHOOL
FACILITY NUMBER: 434412157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited

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BUILDINGS and GROUNDS: Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard. This requirement
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was not met as evidenced by: jutting nails and ripped artificial grass were observed. This poses an immediate risk to Health and Safety to children in care.
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Type A
07/27/2022
Section Cited

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PERSONNEL REQUIREMENTS:
Request a transfer of a criminal record clearance. This requirement was not met as evidenced by: LIC 9182 was in the file but staff was never associated to the facility. This poses an immediate risk to Health and Safety to children in care.
Type B
08/27/2022
Section Cited

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MANDATED REPORTER TRAINING - This requirement was not met as evidenced by: director has not renewed the Mandated Reporter Training. This poses a potential risk to Health and Safety to children in care.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 07/27/2022 02:01 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: APPLETREE MONTESSORI SCHOOL
FACILITY NUMBER: 434412157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2022
Section Cited

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OUTDOOR ACTIVITY SPACE: As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls.
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This requirement was not met as evidenced by: insufficient resilient materials around and under the play structure. This poses a potential risk to Health and Safety to children in care.
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Type B
08/03/2022
Section Cited

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OUTDOOR ACTIVITY SPACE: Sandboxes shall be inspected daily and kept free of hazardous foreign materials. This requirement was not met as evidenced by: sandbox was not covered. This poses a potential risk to Health and Safety to 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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5