434412405-7-2-2019-07-CC-MMAR-BDPVBR-20190702161759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434412405
Report Date: 07/02/2019
Date Signed: 07/02/2019 04:18:16 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:	GOOMER ACADEMY		FACILITY NUMBER:	434412405
ADMINISTRATOR:	DEEPTI GOOMER		FACILITY TYPE:	850
ADDRESS:	2920 FOWLER ROAD		TELEPHONE:	(408) 270-2000
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	74	CENSUS: 43	DATE:	07/02/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kieu Nguyen		TIME COMPLETED:	12:15 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	On 07/02/19 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Annual inspection of Goomer Academy Preschool. Director, Deepti Goomer was not present in the facility and LPA met with Site Supervisor, Kieu Nguyen. Facility License, Personal Rights, Activity Schedules, and Menus were observed to be posted. LPA checked facility files and observed it contained required Designation of Facility Responsibility LIC308 for Kieu Nguyen. Facility's operating days and hours are Monday to Friday 7 AM to 6 PM in Rooms 1, 2 and 3. The physical plant was inspected. LPA toured the building with the Kieu. Indoor space: The classrooms, restrooms, pantry, storage room, and office area were inspected. Present today were: Room 1 (2-3 yr olds): 10 children / 2 teachers Room 2 (3-4 yr olds): 16 children / 2 teachers Room 3 (4-5 yr olds): 18 children / 3 teachers Facility was observed to be in compliance with teacher to children ratio requirement during LPAs' inspection. Children were engaged in various activities both indoor and outdoor under the visual supervision of the teachers. Disinfectants, cleaning solutions, and other items that are dangerous to the health and safety of children were stored in places inaccessible to them. Cabinets, drawers, and rooms used for storage were locked. Furniture and equipment were age appropriate but LPA observed the following items need repair: Room 2: Two child size couches (blue) had large area rips and tear, were patched together with tape. Room 3: a drawer in the room's sink area was broken and without front cover. Each classroom had own restrooms for children and were observed to be in safe, sanitary, and functioning condition. Floors were clean and free from tripping hazard. Foods and beverages were stored safely. Kitchen and food storage area were clean, free of litter, rubbish, and rodents/vermin. Trash cans for solid waste had tight-fitting covers on and were in good repair. Kieur stated that facility does not possess nor store any weapons on the premises. LPA observed a 3A40BC Fire extinguisher, Smoke and Carbon Monoxide Detectors in each classroom. Log shows that the last Fire Drill was conducted in June 2019. Facility does not provide transportation for children, but Kieu understands that children cannot be left alone, unattended in parked vehicles. Continued on Page 2

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019

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: GOOMER ACADEMY	FACILITY NUMBER: 434412405
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/02/2019 Section Cited CCR 101239(n)	1 2 3 4 5 6 7	FURNITURE & FIXTURES 101239(n) Furniture and equipment shall be maintained in good condition, free of sharp, loose or pointed parts. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The two couches were removed immediately and drawer front cover was reinstalled during the inspection. Citation was cleared during inspection.
	8 9 10 11 12 13 14	Per LPA's observations: Room 2: Two child size couches (blue) had large area rips and tear, were patched together with tape. Room 3: a drawer in the room's sink area was broken and without cover. This poses a potential risk to the health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019

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: GOOMER ACADEMY	FACILITY NUMBER: 434412405
	VISIT DATE: 07/02/2019

NARRATIVE

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Outdoor Space: Outdoor playground was inspected and observed to be safe. The play equipment was maintained in good condition and free of hazards. Areas around and under high climbing equipment and slides were cushioned with soft rubber material that absorbs falls. There were no bodies of water observed. There was a shed on the corner which was observed to be locked. Drinking water is arranged to be readily available to children during indoor and outdoor activities by water fountains and personal water bottles.

File Review: Children sign in and out procedures and logs were reviewed. A sampling of ten Children's files and nine Staff files was taken for review. All child files contained Admission Agreement, Immunizations, Health Reports, Parents and Personal Rights. All staff files contained required educational qualifications, Employee RIghts, Immunizations, Mandated Reporter Training AB1207, valid Pediatric CPR/First Aid certifications. Children's Roster was reviewed, and a copy obtained.

Kieu stated that facility does handle medications and currently has one child in care who require Incidental Medical Services. Facility has an approved IMS Plan on file with San Jose Regional Office. LPA reviewed storage of medication and equipment / supplies. Isolation of sick child was discussed, and Kieu explained that a sick child is brought to the office area to be isolated from other children. An adult restroom is used if necessary. Child is always under visual supervision while being cared for.
For IMS information, see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.
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.

Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility.

LPA reminded 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 per day with a maximum of $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day with a maximum of $3000.00 per person.
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SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019

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: GOOMER ACADEMY	FACILITY NUMBER: 434412405
	VISIT DATE: 07/02/2019

NARRATIVE

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LPA also reviewed those violations that would result in an immediate assessment of civil penalty in the amount of $500. Director is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.

In the areas that were evaluated, regulatory violations were observed. Therefore, citation was issued. Exit Interview was conducted, where this report, the citation, plan of corrections, and appeal rights were reviewed and discussed with Kieu. Report was signed by Site Supervisor, Kieu Nguyen confirming receipt of documents. She was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Website for provider resources:
http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

childcareadvocatesprogram@dss.ca.gov

"Mandated Reporter" training for CA Child Care Providers that all staff are required to complete as of January 1, 2018. [Starting May 2019, both General Training followed by Child Care Providers Training is required to be taken]. The website for the online training is: http://www.mandatedreporterca.com/training/childcare.htm.

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.

LPA's laptop performed a Consistency Check at 12:10 PM. LPA left the facility and returned at 4:00 PM after check was complete. Representative signatures were obtained on the 809 report.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019

LIC809 (FAS) - (06/04)

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