434414750-8-10-2022-07-CC-MSMS-CH6TW8-20220810150506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414750
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:05:13 PM

Document Has Been Signed on 08/10/2022 03:05 PM - It Cannot Be Edited

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:	STACY GUMFORY-ESQUIBEL		FACILITY TYPE:	850
ADDRESS:	750 LAKECHIME DRIVE		TELEPHONE:	(408) 522-8213
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94089
CAPACITY:	48	CENSUS: 0	DATE:	08/10/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Stacy Gumfory-Esquibel		TIME COMPLETED:	03:15 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	Licensing Program Analyst (LPA) Mel Matos met with Stacy Esquibel, preschool program manager, for an announced case management inspection. Purpose of today's case management inspection: The Facility is requesting to add Room 27 to the existing preschool license. The capacity remains unchanged at 48 preschool children. Hours of operation: 8:15 AM to 11:15 AM (AM session) and 12 PM to 3 PM (PM session) Monday to Friday during the calendar school year for Sunnyvale School District. Stacy states that school is currently on summer recess and scheduled to resume on Wednesday August 17, 2022. The Facility is currently licensed in the following rooms: Rooms P1, P2, & Y3. Measurements for Rooms P1, P2, Y3, and 27 are as follows: ROOM P1: 39.083 x 26.833 = 1,048.714 (minus 5.000 x 2.000 = 10.000) = 1,038.714 ROOM P2: 39.083 x 26.833 = 1,048.714 (minus 5.000 x 2.000 = 10.000) = 1,038.714 ROOM Y3: 39.000 x 23.000 = 897.000 (minus 9.417 x 13.500 = 127.129) = 769.871 ROOM 27: 29.000 x 23.750 = 688.750 *TOTAL INDOOR CLASSROOM SPACE: 3,536.049 sq. ft. divided by 35 = 101 preschool children.* There is sufficient sinks (6), toilets (6), chairs (48), tables (12), cubbies (48), supplies, and equipment for the children within all four rooms. The program operates two part time sessions daily (AM/PM sessions) and thus no napping is provided. The Facility only provides AM/PM snacks for the preschool children. Drinking water is available for the preschool children indoors. The preschool 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.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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: 08/10/2022

NARRATIVE

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LPA observed that the preschool playground areas (near Room P2 & Y3) are surrounded by appropriate fencing. There is adequate equipment, supplies, and toys for the preschool children outdoors. The preschool playground areas have age appropriate & secure play structures. There is a waiver on file for shared playground space for the playground area near Room P2. There are sufficient resilient materials underneath and surrounding the play structures in both playgrounds. Shade is provided via trees and building overhang. Drinking water is available for the preschool children outdoors.

OUTDOOR MEASUREMENTS:

Preschool Playground (near Room P2) - 112.000 x 120.000 = 13,440.000
Preschool Playground (near Room Y3) - 82.500 x 47.500 = 3,918.750

TOTAL OUTDOOR SPACE: 17,358.750 sq. ft. divided by 75 = 231 preschool children.

A fire inspection was completed by the Sunnyvale Department of Public Safety today and LPA was informed by Fire Marshal Chris Jueseekul that the fire inspection is approved as of today, August 10, 2022.

Exit interview conducted and report was reviewed with Stacy Esquibel, preschool program manager, and advised her that Room 27 is approved and will be added to the license effective today, August 10, 2022.

Notice of site visit issued and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC809 (FAS) - (06/04)

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