434413116-5-17-2023-07-CC-PHEZ-CRWPVP-20230517113927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413116
Report Date: 05/17/2023
Date Signed: 05/17/2023 11:39:36 AM

Document Has Been Signed on 05/17/2023 11:39 AM - 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	ABC EVERGREEN PRESCHOOL		FACILITY NUMBER:	434413116
ADMINISTRATOR:	JENNY YEN HA		FACILITY TYPE:	850
ADDRESS:	2650 ABORN ROAD		TELEPHONE:	(408) 791-7772
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY:	80	CENSUS: 31	DATE:	05/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Jenny Yen Ha		TIME COMPLETED:	11:45 AM

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 5/17/2023 Licensing Program Analyst (LPA) Pete Hernandez conducted an unannounced required 1 year inspection at ABC Evergreen Preschool. LPA met with Director, Jenny Yen Ha and explained the purpose of today's visit. Facility's operating days and hours are Monday to Friday 7:30 AM to 6:00 PM in Rooms 1, 2, 3 (now combined as a single preschool room), and Room 4, Grace Halls A & B. Room 5 is used as a storage area. Facility’s License, Parents’ Rights Poster PUB393, Personal Rights, Menus and Activity Schedules were observed to be posted. The physical plant was inspected. LPA toured the building with the Director. Indoor space: The classrooms, restrooms, pantry, storage room, and office area were inspected. At the time of rooms walk through, LPA observed the following teacher/child ratios in: Grace Hall A: 11 children, 3 staff (2 fully qualified, 1 aide) Grace Hall B: 20 children, 2 staff (1 fully qualified, 1 aide) Room 1-4: 0 children, 0 staff (all fully qualified). Children from these rooms were combined and playing in the playground. Facility was observed to be in compliance with teacher to children ratio requirement during LPAs' inspection. Children were engaged in various activities under the visual supervision of the teachers. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. Restrooms for children were observed to be in safe, sanitary, and functioning condition. Floors were clean and free from tripping hazard. Foods and beverages were stored safely. 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. Continued on next page. Report dated 5/17/2023

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ABC EVERGREEN PRESCHOOL	FACILITY NUMBER: 434413116
	VISIT DATE: 05/17/2023

NARRATIVE

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irector stated that facility does not possess nor store any weapons on the premises. LPA observed 2A10BC Fire extinguisher, Smoke and Carbon Monoxide Detectors, fire pull stations, and sprinkler system. Director states that the last Fire Drill was conducted but not documented. Facility does not provide transportation for children, but Director understands that children cannot be left alone unattended in parked vehicles.
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 material that absorbs falls. There were no bodies of water observed. Drinking water is arranged to be readily available to children during indoor and outdoor activities.

File Review: Children sign in and out procedures and logs were reviewed. All children were signed in by their authorized representative. A sampling of 10 Children's files and 5 Staff files was taken for review. All child files contained Admission Agreements and Staff files contained documentation of educational credits. There was at least one Teacher with current certification in Pediatric CPR and First Aid present at the facility during inspection. Children's Roster was reviewed.

Director stated that facility does handle medications and currently have children in care who require Incidental Medical Services. Facility will develop a plan and send to CCLD for approval. LPA reviewed storage of medication and equipment / supplies. Isolation of sick child was discussed, and Director 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 AB 2370 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.
Continued on next page. Report dated 5/17/2023

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ABC EVERGREEN PRESCHOOL	FACILITY NUMBER: 434413116
	VISIT DATE: 05/17/2023

NARRATIVE

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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.
LPA also reviewed with Director the 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.

"Mandated Reporter" training for CA Child Care Providers per AB 1207 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.

Should there ever be issuance of Type A citations today, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, See LIC809D. An exit interview was conducted, and was reviewed with the licensee. A copy of this report and appeals rights was discussed and left with the Licensee, Jenny Yen Ha, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/17/2023 11:39 AM - 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-DAY CARE, 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: 05/17/2023

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in all Staff (S1) through (S5) vwhich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2023
	Plan of Correction
1 2 3 4	LPA provided the web address https://www.mandatedreporterca.com for Licensee to access the required training. BY POC DUE DATE:5/24/2023, Licensee and Staff will complete the training and send a copy of the Certificate of Completion to Licensing Office.

Type B

Section Cited

CCR

101216(f)

Personnel Requirements

(f) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2023
	Plan of Correction
1 2 3 4	BY POC DUE DATE 5/24/2023; Licensee will complete the training and send a copy of the Certificate of Completion to Licensing Office.

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: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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