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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415604
Report Date: 10/29/2020
Date Signed: 10/29/2020 01:12:57 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:PEPPERTREE SCHOOLS COTTAGE HOUSEFACILITY NUMBER:
434415604
ADMINISTRATOR:THERESA BECKERDITEFACILITY TYPE:
840
ADDRESS:16035 LOS GATOS ALMADEN ROADTELEPHONE:
(408) 356-3211
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY:10CENSUS: 0DATE:
10/29/2020
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jeffrey Osborn, Danna Matthew Osborn, Deepak Gupta, and Dmitry KlimkoTIME COMPLETED:
01:00 PM
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Carol Marcroft, Regional Manager (RM), Diana Stephenson, Licensing Program Manager (LPM), and Mel Matos & Ofelia Calivo, Licensing Program Analysts (LPAs) met with Jeffrey Osborn, Applicant representative, Danna Matthew Osborn, Applicant’s spouse/director, and Deepak Gupta & Dmitry Klimko, partners in LLC, virtually via Microsoft Teams Meeting to discuss the pending application submitted on February 28, 2020 for Peppertree Schools LLC.

Pending/incomplete items are as follows:

1) Application for a Child Care Center License (LIC 200A): can only be signed by Jeffrey Osborn, Applicant representative.
2) Lease agreement: needs to have a commencement date noted.
3) Monthly Operating Agreement (LIC 401): need completed form for each individual license.
4) Admission agreement: must list rate of “optional services”, modification conditions (minimum 30-day advance notice required for modification of agreement, including tuition change), and reason(s) for termination services.
5) Sample menus: food portion for age groups must be listed on the menu per Title 22. Section 101227 (Food Services). Times must match daily schedule.
6) Financial Information Release and Verification (LIC 404): must have signed form for every account connected to the LLC. A minimum of three months of reserves is required.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PEPPERTREE SCHOOLS COTTAGE HOUSE
FACILITY NUMBER: 434415604
VISIT DATE: 10/29/2020
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7) Criminal Background Clearance Transfer Request (LIC 9182): need completed form and copy of valid driver's license for Theresa Beckerdite, director.
8) Balance Sheet (LIC 403): need one for each license and must be signed by preparer and Applicant representative.
9) Preventative Health/Safety course: Theresa needs to retake the 8 hour Preventative Health/Safety course that covers nutrition and lead exposure.
10) Health Screening Report (LIC 501): need one for Jeffrey including TB test results within past 12 months.
11) Mandated Reporter Training for Child Care Workers: need proof of completion for Theresa.
12) Vaccination requirements: need Tdap and Mmr for Jeffrey.
13) Fire inspection approval from Santa Clara County Fire Department.

All parties agreed to have all pending/incomplete items listed in this report completed & submitted to the San Jose Child Care District Office by Monday November 30, 2020.

All parties were informed that due to the current COVID-19 pandemic and "Shelter In Place" Order, today's report (Facility Evaluation Report - LIC 809) will be emailed to the following: Jeff Osborn (jeff.osborn@peppertreeschools.com), Danna Matthew Osborn (danna.osborn@peppertreeschools.com), Deepak Gupta (deepak.msb@gmail.com), and Dmitry Klimko (dmitryklimko@gmail.com) a with "Read Receipt" notification.

Jeffrey Osborn, Applicant, understands that his response to the email is considered an acknowledgement of "receipt" of today's report.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
LIC809 (FAS) - (06/04)
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