<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413116
Report Date: 10/23/2019
Date Signed: 10/24/2019 01:30:55 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Jenny Yen HaTIME COMPLETED:
05:30 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 10/23/19 Licensing Program Analysts (LPAs) Monica Mathur and Dung Mac conducted a Case Management inspection at ABC Evergreen Preschool.

LPAs conducted inspection of the Large Hall that houses Room A and Room B. The rooms are divided by a row of tall shelves and teachers on one side do not have direct visual supervision of children on the other side.

LPAs observed in Room A there were 26 children and 2 fully qualified teachers present. They were out of teacher/child ratio by 2 children. In Room B, there were 2 fully qualified teachers with 16 children, and they were in ratio. A Type B citation was issued because Room A was out of ratio, and although there were teachers in Room B on the other side, they did not have direct visual supervision of children in Room A due to tall shelves dividing the rooms. This poses a potential risk to health and safety of children.

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)
Page: 1 of 2
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
10/25/2019
Section Cited

1
2
3
4
5
6
7
101216.3(a) Teacher Child Ratio:There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance [...]. This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Per LPA's inspection, In Room A there were 2 fully qualified teachers and 26 children present, out of ratio by 2 children. This poses a potential risk to 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
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)
Page: 2 of 2