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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414755
Report Date: 08/14/2019
Date Signed: 08/14/2019 04:56:58 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:EVERGREEN MONTESSORI SCHOOL - ARFACILITY NUMBER:
434414755
ADMINISTRATOR:PRAKASH, SUNITAFACILITY TYPE:
850
ADDRESS:3000 ABORN ROADTELEPHONE:
(408) 603-5000
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:50CENSUS: 33DATE:
08/14/2019
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sunita PrakashTIME COMPLETED:
05:00 PM
NARRATIVE
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On 08/14/19 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Annual inspection of Evergreen Montessori - AR Preschool today. LPA met with Owner, Sunita Prakash and visiting Director from Fowler campus, Varsha Kumar and explained the purpose of today's visit. Varsha stated the Director for this campus Sneh Ayare was on vacation for the week. Facility’s License, Activity Schedules, and Menus were observed to be posted but LPA did not observe Parents’ Rights Poster PUB393 posted in the facility. Facility's operating days and hours are Monday to Friday 7:30 AM to 6:00 PM in Rooms 1 and 2. There are an active waiver on file for use of electronic system for sign in and out.
The physical plant was inspected. LPA toured the building with the Director.
Indoor space:
Room 1 (Cypress): 20 children napping / 4 teachers
Room 2 (Juniper): 13 children napping / 2 teachers
Facility was observed to be in compliance with teacher to children ratio requirement during LPAs' inspection.
The classrooms, restroom shared between both rooms, kitchen, pantry, storage room, lobby and office area were inspected. Children were engaged in various activities under the visual supervision of the teachers. Disinfectants, cleaning solutions, and other items that are dangerous to the health and safety of children were stored in places inaccessible to them. Cabinets, drawers, and rooms used for storage were locked. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. Restroom for children was 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.
Continued on Page #2. Report dated 08/14/19
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
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 5
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: EVERGREEN MONTESSORI SCHOOL - AR
FACILITY NUMBER: 434414755
VISIT DATE: 08/14/2019
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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 (US DOJ) 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. 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.

Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA will send a copy of the “Lead Poisoning Facts Information Flyer” to the facility.
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.

In the areas that were evaluated, regulatory violations were observed. Therefore, citations were issued. Exit Interview was conducted, where this report, the citations, plan of corrections, and appeal rights were reviewed and discussed with Owner. Report was signed confirming receipt of documents. Owner was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. Licensee stated facility is signed up for Quarterly updates for Newsletters
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.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: EVERGREEN MONTESSORI SCHOOL - AR
FACILITY NUMBER: 434414755
VISIT DATE: 08/14/2019
NARRATIVE
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Center serves Lunch, AM, PM snack. Water is readily available via pitchers, disposable cups and child's personal water bottles. Trash cans for solid waste had tight-fitting covers on and were in good repair. Director stated that facility does not possess nor store any weapons on the premises. LPA observed a 3A40BC Fire extinguisher, Smoke and Carbon Monoxide Detectors, fire pull stations, and sprinkler system. Log shows that the last Fire Drill was conducted on 05/15/19. 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 via water fountain to children during outdoor activities.

File Review: Electronic children sign in and out procedures and logs were reviewed. Per LPA's review, at least 4 children present today were not signed in by their authorized representative. The electronic system is placed in the lobby, Owner stated that parents are expected to sign in/out daily but teachers in the classrooms are unable to verify whether parents signed in/out. Licensee was not fully familiar using the electronic system to access records, was unable to show signed in record for Room 1 children. A sampling of 10 Children's files and 7 Staff files was taken for review. All child files contained Admission Agreement, Physician's Report, Identification & Emergency Information, Parent Rights, Personal Rights, Consent for Emergency Medical Treatment, Immunizations. Some staff files did not contain immunizations for measles, pertussis, flu/opt out, Health Screening Report LIC503. All staff had Mandated Reporter Training per AB1207 on file. 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, and Licensee agreed to send a copy to CCLD.

Director stated that facility does handle medications and currently have children in care who require Incidental Medical Services. Facility has an approved IMS Plan on file with San Jose Regional Office. LPA reviewed storage of medication and equipment / supplies. LPA observed the Epinephrine medications for two IMS children were expired. Owner agreed to remind parents to send new medications.
Continued on Page #3. Report dated 08/14/19
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: EVERGREEN MONTESSORI SCHOOL - AR
FACILITY NUMBER: 434414755
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2019
Section Cited
CCR
101218.1(c)
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101218.1(c) Admission Procedures and Parental & Authorized Representative's Rights: The licensee shall post the PUB 393 (8/02), Child Care Center Notification of Parents' Rights Poster in a prominent, publicly accessible area in the child care center at all times. This requirement is not met as evidenced by:
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LPA printed out PUB393 and Licensee posted the poster in the facility in a place of public view. Citiation was cleared during the inspection.
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Per LPA's observation, The Parents' Rights Poster PUB393 was not posted in the facility. Licensee stated she was unaware of the requirement. This poses a potential risk to the health and safety of children.
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Type B
08/21/2019
Section Cited
CCR
101229.1
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101229.1 Sign In and Sign Out: Children are required to be signed in by their authorized representative and facility is required to maintain a functioning sign in/out system in place. This requirement is not met as evidenced by:
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As a plan of correction, Licensee agreed to do the following today:
- email, send notes to all parents for sign/out reminder.
- place a reminder note in the lobby area for parents.
- Note to all staff regarding importance to check sign in/out daily with parents and get staff acknowledgement signatures on it.
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Per LPA's review of records, at least 4 children present today were not signed in by their authorized representative. The electronic system is placed in the lobby, parents are expected to sign in/out daily but teachers in the rooms are unable to verify whether parents signed in/out. Licensee was not fully familiar using the electronic system to access records,was unable to show signed in record for Room 1 children.This poses a potential risk to the health and safety of children.
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Owner ensured the above plans were implemented during the inspection. Citation was cleared during the inspection.
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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: EVERGREEN MONTESSORI SCHOOL - AR
FACILITY NUMBER: 434414755
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2019
Section Cited
HSC
1596.7995
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HEALTH & SAFETY CODE. Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. […]. The day care center shall maintain documentation of the required immunizations. This requirement is not met as evidenced by:
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By POC Due Date Licensee agreed to obtain and send to CCLD verifications of immunizations for Staff 1,2,3,4.
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 Staff 1, 2, 3, 4 has been working at the center, but the center does not have documentation that Staff 1, 2, 3, 4 is immunized against Measles, Pertussis and Influenza. This poses a potential risk to the health and safety of children in care.
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Type B
09/13/2019
Section Cited
CCR
101216(g)(2)
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Personnel Requirements: All personnel including the licensee shall have a health-screening report, including specified information, signed by the person who performed it. This requirement is not met as evidenced by:
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To be completed by the end of the day on the POC due date, the Licensee agreed to ensure all personnel files are complete, including all health screening assessments and immunizations
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Staff 2 do not maintain health screening report on file, including TB test results. This presents a potential risk to the health and safety of the children in care.
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Licensee will obtain and submit copy of Health Screening Report including TB clearances for Staff 2.
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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5