434414750-5-8-2019-07-CC-MSMS-BBYPCC-20190508111144

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414750
Report Date: 05/08/2019
Date Signed: 05/08/2019 11:11:49 AM

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:	SSD STATE PRESCHOOL-LAKEWOOD		FACILITY NUMBER:	434414750
ADMINISTRATOR:	KIM ANH LE		FACILITY TYPE:	850
ADDRESS:	750 LAKECHIME DRIVE		TELEPHONE:	(408) 522-8213
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94089
CAPACITY:	48	CENSUS: 41	DATE:	05/08/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Grissel Ramirez		TIME COMPLETED:	11:10 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	Licensing Program Analyst (LPA) Mel Matos met with Grissel Ramirez, administrative assistant, for an unannounced annual/random inspection. LPA toured the indoor and outdoor space of the Facility with Grissel during today's inspection. LPA notes that the Facility is licensed in Room P2 & Y2 on the campus of Lakewood Elementary School. Hours of operation are: 8:15 AM-11:15 AM & 12 PM to 3 PM Monday to Friday. The Facility is open during the calendar school year for the Sunnyvale School District and closed during school holiday/recess periods. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus, and Activity Schedule. The Facility has one waiver (shared playground space with Kindergarten program) and is in compliance with the terms & conditions of the waiver. The program is operated by the Sunnyvale School District and all criminal background checks for staff are handled by the Department of Education and thus do not come under the jurisdiction of Community Care Licensing Division. LPA reviewed ten children's and six staff files (director, 2 teachers, & 3 aides) during today's inspection. Each child's file reviewed contains the Information and Emergency Information form (LIC 700). The director and teacher files contains the required transcripts/verification of experience. Grissel and all teachers has current CPR and First Aid certifications on file. Grissel understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips). LPA observed that the teacher/child ratio was in compliance during today's inspection. Grissel understands the conditions, limitations, and capacity specifications of the Facility license. Grissel understands that children shall be visually supervised at all times. LPA observed one director, two teachers, and 3 aides with 41 preschool children during today's inspection. LPA notes that the Facility is Title 5 funded and thus Title 5 ratios apply. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 05/08/2019):

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019

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: SSD STATE PRESCHOOL-LAKEWOOD	FACILITY NUMBER: 434414750
	VISIT DATE: 05/08/2019

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 05/08/2019):

LPA observed that Rooms P2 & Y3 is clean and safe for all children and staff. Grissel states that staff from the Sunnyvale School District clean the Facility Monday through Friday in the evenings. Drinking water is readily available for the children in Rooms P2 & Y3 and in the outdoor playground area via water fountain, water bottles, & water cooler/disposable cups. LPA observed solid waste containers with tight-fitting lids in Rooms P2 & Y3 and outdoors. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Grissel states that there are no weapons or firearms on the premises.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. The Facility only serves snacks since it only operates AM & PM half day programs. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. Cleaning supplies are inaccessible to the children and stored inaccessible to children.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground areas utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. There is sufficient resilient materials (artificial grass with rubber padding & rubber squares) in the outdoor playground areas. LPA did not observe any bodies of water.

No deficiencies issued during today's inspection.

LPA conducted an exit interview with Grissel and she agreed to submit an updated Personnel Report (LIC 500) and Emergency Disaster Plan (LIC 610) to LPA Matos by Friday May 17, 2019.

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

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019

LIC809 (FAS) - (06/04)

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