434414750-9-5-2024-07-CC-MSMS-D8TPDX-20240905111416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414750
Report Date: 09/05/2024
Date Signed: 09/05/2024 11:14:21 AM

Document Has Been Signed on 09/05/2024 11:14 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 CC RO, 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: 21	DATE:	09/05/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Stacy Gumfory-Esquibel		TIME COMPLETED:	11:30 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 Stacy Gumfory-Esquibel, Licensee Representative, for an unannounced Required - 3 year inspection. LPA toured the indoor and outdoor space of the Facility during today's inspection. LPA notes that the Facility is licensed in Room PS1 & PS2 on the campus of Lakewood Elementary School. Hours of operation are: 8:15 AM-11:15 AM (AM session) & 12 PM to 3 PM (PM session) 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), snack menu, and Activity Schedule. LPA reviewed five children's and three staff files (1 director and 2 teachers) during today's inspection. Each child's file reviewed contains the required documents; including the Information and Emergency Information form (LIC 700) and immunization records. All staff files reviewed contain the required documents; including transcripts/verification of experience/immunization records, and Health Screening Report. All staff have current certificates of completion of the Mandated Reporter Training for Child Care Workers on file. Last fire/disaster drill was completed on August 29, 2024. Director and two teachers has current CPR and First Aid certifications on file. Stacy 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. LPA observed ten preschool children with one teacher and two aides in Room P2 and eleven preschool children with the Director, one teacher, and two aides in Room Y3 during today's inspection. Director understands the conditions, limitations, and capacity specifications of the Facility license. Stacy understands that children shall be visually supervised at all times. Rooms P1 and 27 were not in use during today's inspection. LPA notes that the Facility is Title 5 funded and thus Title 5 ratios apply. Any child(ren) who exhibit symptoms of illness including, but not limited to, fever or vomiting, are not accepted in care. Any child(ren) who become ill during the day, shall be isolated in the director’s office area. LPA observed that Rooms PS2 and Y3 are clean and safe for all children, staff, and visitors. The Facility has adequate ventilation, including central air conditioning/heating. LPA observed that all furniture and equipment is in good condition and safe for the children. Stacy states that staff from the Sunnyvale School District provides cleaning services Monday through Friday in the evenings. Drinking water is readily available for the children in Rooms PS1 & PS2 and in the outdoor playground area via water fountains, water bottles, & water jugs/disposable cups. 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. Stacy states that there are no weapons or firearms on the premises. The Facility has functioning carbon monoxide detectors.

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SSD STATE PRESCHOOL-LAKEWOOD	FACILITY NUMBER: 434414750
	VISIT DATE: 09/05/2024

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
26
27
28
29
30
31
32

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. LPA observed solid waste containers with tight-fitting lids in Rooms P2 & Y3 and outdoors. Cleaning supplies are inaccessible to the children and stored inaccessible to children. Any poisons are stored in the locked janitor's closet on campus. LPA observed a complete First Aid kit in the Facility. Stacy understands that smoking is not allowed on the Facility premises.

Stacy states that the Facility does not administer any medications at this time. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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

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 are secure play structures that are age appropriate for the preschool children. Shade is provided by trees and building overhang. There is sufficient resilient materials in the outdoor playground areas. LPA did not observe any bodies of water. Facility does not provide transportation.

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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Exit interview conducted and report was reviewed with the Licensee Representative, Stacy Gumfory-Esquibel,. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2