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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412157
Report Date: 02/10/2020
Date Signed: 02/10/2020 12:33:43 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: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: 33DATE:
02/10/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Nilanthi Renuka Jayasinghe [A.K.A. Renu Jaya]TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Tuoc Doan conducted an unannounced Annual inspection of the Preschool. LPA met with Licensee/Director Nilanthi Renuka Jayasinghe [A.K.A. Renu Jaya] and explained to her the purpose of the inspection. Facility's License, Notification of Parents’ Right Poster, Children's Personal Rights, and Child Car Seat Law were observed to be posted. Operating days and hours are Monday through Friday from 08:00 AM to 06:00 PM.

LPA inspected the building inside and out. The Preschool is located in two rooms (classroom 1 and classroom 2) on the property of Sunnyvale Seventh-Day Adventist Church. The Preschool classrooms, Office area, two children restrooms, and storage areas were inspected. Furniture and equipment were observed to be age appropriate and in good condition. Restrooms for children to use were observed to be in operating condition. Floors were clean. Disinfectants, cleaning solutions, poisons, sharps, and other items that are dangerous to children were stored inaccessible. Facility provides two snacks a day. Snack menu was posted. Food are stored in the Kitchen. Trash can for solid waste had tight fitting covers on.

Outdoor activity space was enclosed by fence. LPA observed play equipment were maintained in a good condition, free of hazards. Areas around and under high climbing equipment were cushioned with material that absorbs falls. There were no bodies of water observed. Director stated that facility does not have weapons on the premises. Drinking water was arranged to be readily available to children. Shade is provided by trees. LPA observed that facility has a fire sprinkler system, smoke and carbon monoxide detectors, and a fully charged fire extinguisher last serviced on 02/2019 in the classroom. Fire/disaster drill log recorded that the last fire drill was conducted on 02/06/2020. The facility does not provides transportation service to children.

LPA reviewed facility's roster, and sign in and out procedure and record. A sampling of children and staff files was selected for review.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2020
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 4
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: 02/10/2020
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Children records reviewed includes Admission Agreement, Identification and Emergency Information, Consent for Emergency Medical Treatment form, Medical Assessment, and immunization.

Staff records reviewed include Criminal Record and Child Abuse Index Background Check Clearance, Health Screening Report with TB Clearance, Immunization Record for Measles and Pertussis, Education Qualification, and required Training. LPA reminded Director that the AB1207 Mandated Reporter Training needs to be renewed every two years.

LPA reminded Licensee/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 up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.

Facility's Incidental Medical Services (IMS) policy was discussed with Licensee/Director. Licensee/Director stated that currently there are no children in care who require 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 about Child Care centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA also reviewed with Licensee/Director the violations that would result in an immediate $500 civil penalty assessment. Facility is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Regulations etc. Beginning January 1, 2019 AB2370 requires licensed centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families.

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

A NOTICE OF SITE VISIT WAS ISSUED 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: 02/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 02/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2020
Section Cited

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PERSONNEL REQUIREMENTS. At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.
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This requirement is not met as evidenced by:
Per review of records, none of the staff present during today's inspection can show proof that they have current certification in Pediatric CPR/1st Aid Training. This poses a potential risk to the health and safety of children in care.
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Type B
02/21/2020
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, Licensee did not
obtain Child 1's written medical assessment.
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Child 1 has 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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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: 02/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 02/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2020
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, Licensee does not
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have documents showing that Child 1 and Child 2 have immunizations. 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: 02/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4