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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413116
Report Date: 10/23/2019
Date Signed: 10/24/2019 01:30:19 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:ABC EVERGREEN PRESCHOOLFACILITY NUMBER:
434413116
ADMINISTRATOR:JENNY YEN HAFACILITY TYPE:
850
ADDRESS:2650 ABORN ROADTELEPHONE:
(408) 791-7772
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:80CENSUS: 42DATE:
10/23/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jenny Yen HaTIME COMPLETED:
03:53 PM
NARRATIVE
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On 10/23/19 Licensing Program Analyst (LPAs) Monica Mathur and Dung Mac conducted an unannounced Plan of Correction Inspection (POC) at ABC Evergreen Preschool. LPAs met with Director, Jenny Yen Ha and explained the purpose of today's inspection.

On 10/03/19 during an unannounced Annual/Random inspection, facility was issued citations for the following:
Building & Grounds (Type A) - Cleaners, disinfectants in accessible area
Napping Equipment (Type B) - bedding sheets coming in contact with each other

During today's POC inspection, LPAs observed all disinfectants and cleaning supplies were store in places inaccessible to children. All bedding was stored in a cabinet, in separate compartments and were not coming in contact with each other. Citations were cleared and Letters of Clearance given to Director. LPAs observed that report was posted adjacent to the entrance of the facility, however, did not observe signed Statement Acknowledging Receipt of Licensing Report LIC9224 in any child file. Director states she was under the impression signatures could be obtained up to 30 days from 10/03/19, has not been able to provide the licensing report dated 10/03/19 or LIC9224 to any parent yet.

A deficiency was cited today. This report, citation, appeal rights was discussed with 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.

** LPA's laptop went into consistency check during review with Director. LPA returned to facility on 10/24/19, signatures were completed and a copy given to facility on 10/24/19.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019
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: ABC EVERGREEN PRESCHOOL
FACILITY NUMBER: 434413116
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2019
Section Cited

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1596.8595(c)(1) HEALTH & SAFETY CODE: A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation [...]. This requirement is not met as evidenced by:
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Per LPA's review of 10 child files, did not contain the Statement Acknowledging Receipt of Licensing Report (LIC9224) dated 10/03/19. Director states she assumed she had 30 days to give them out, has not been able to give out the report or LIC9224 to parents yet. 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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2019
LIC809 (FAS) - (06/04)
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