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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412157
Report Date: 02/28/2024
Date Signed: 02/28/2024 04:16:23 PM


Document Has Been Signed on 02/28/2024 04:16 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 CC RO, 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:22CENSUS: 18DATE:
02/28/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Heather Hicks, Sunita Sahota and Renu JayaTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Mandeep Kaur and Marilou Monico conducted an unannounced Required -3 Year inspection. LPAs met with teacher Heather Hicks and explained the reason for the inspection. Later on, Teacher, Sunita Sahota joined the tour and Heather went back to the classroom. Present during today's inspection were 18 children and at least three (3) staff. The center was within ratio during today's inspection.

There is a board to post required postings in the office with notification of parent's rights, and car seat law, but missing License. Teachers, Sunita and Heather were advised to move the required positing including license to the public view area next to the Room 6 and Room 7. The hours of operation are Monday through Friday 8:30AM to 6:00 PM.

LPAs toured the inside and outside of the center with Teacher, Sunita Sahota. Disinfectant and cleaning supplies were observed to be inaccessible. Room 6 and Room 7 were observed. There are adequate toys and equipment for children. Room 7 was observed to be clean and floor were free of trip hazard. Room 6 carpet needs to be cleaned: stained in several areas of the carpet. There is a fully charged 3A40BC fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 02/26/2024. LPAs observed two toilets and two sinks available for the children in the bathroom labeled "Women".

The play area is fenced. Areas around play structure have resilient material (wood chips). There were no bodies of water observed during today's inspection. Shade is provided by pergola and trees. There is a water fountain located in the play ground.

The center does provide morning and afternoon snacks to the children. Snacks are prepared in the kitchen area that has hot and cold running water. Snacks includes crackers and fruits, prepared by the staff daily. Drinking water is provided through gallon water and cups.



Continuation on next pages:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: APPLETREE MONTESSORI SCHOOL
FACILITY NUMBER: 434412157
VISIT DATE: 02/28/2024
NARRATIVE
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Director, Renu Jaya joined later during the visit.

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.

LPAs referred Director, Renu Jaya, to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) 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/.

A copy of the facility roster was obtained during today's inspection. Six (6) children's files were reviewed during today's inspection. The records reviewed include but not limited to parent's right and immunization records.

Four (4) staff files were reviewed. The records reviewed include but not limited to education credit and Mandated Reporter training. Two of the staff has a valid CPR/1st Aid, which expires on 07/21/2024 and 07/31/2024.

All staff present have cleared criminal record and child abuse index. 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.



Continuation on next pages:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: APPLETREE MONTESSORI SCHOOL
FACILITY NUMBER: 434412157
VISIT DATE: 02/28/2024
NARRATIVE
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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.

The center will submit the following:
- Proof that Lead Testing is scheduled and lead testing is done.
- Permission letters for the Temporary Locations listed under Section IV of LIC 610 ( Emergency Disaster Plan for Child Care Centers).
-Copy of the updated Children Roster.

As a result of this inspection, Type B citations were issued. Exit interview conducted and report was reviewed with Director, Renu Jaya . A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 02/28/2024 04:16 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
SAN JOSE CC RO, 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: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
WD
101700(b)
Written Directives for Lead Testing
(b) All licensed Child Care Centers operating in buildings constructed before January 1, 2010, shall test their water for lead pursuant to these written directives.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on the licensee statement and record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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2
3
4
By 03/06/2024, the center will submit the proof of the work order. By POC 03/28/2024, the center will submit lead test results.
Type B
Section Cited
CCR
101238.3(b)
Indoor Activity Space
(b) The floors of all rooms shall have a surface that is safe and clean.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above in Room 6 as carpet needs to be cleaned: stained in several areas of the carpet which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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By POC, 03/13/2024, the center will submit the work order and pictures of Room 6 that carpet has been cleaned.
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: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 02/28/2024 04:16 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
SAN JOSE CC RO, 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: 02/28/2024

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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3
4
Based on record review, the licensee did not comply with the section cited above for 3 of the staff ( #1, #3 and #4) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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By Poc, by 03/13/2024, the center will submit the certificate of completion of the Mandatory Reprter Tranining (AB1207).
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 record review, the licensee did not comply with the section cited above in 2 of the staff (#3 and #4) which poses a potential health, safety or personal rights risk to persons in care. Staff #3 is missing Measles and Pertussis, Staff #4 missing Measles.
POC Due Date: 03/13/2024
Plan of Correction
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By POC, by 03/13/2024, the center will submit the proof of the Immunization records: Staff # 3 missing Measles and pertussis and Staff #4 missing Measles.
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: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 02/28/2024 04:16 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
SAN JOSE CC RO, 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: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220.1(g)
Immunizations
(g) 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:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 of the children (Child #1 and Child #4). Child # 1 missing immunization records and physician report and Child # 4 missing Immunization records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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By POC, by 03/13/2024, the center will submit the completed Calfornia School Immunization records. Child # 1 missing immunization records and physician report and Child # 4 missing Immunization records.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8