434415604-1-21-2021-07-CC-MSMS-BXGUVV-20210121145546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415604
Report Date: 01/15/2021
Date Signed: 01/21/2021 02:56:34 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 HOUSE		FACILITY NUMBER:	434415604
ADMINISTRATOR:	THERESA BECKERDITE		FACILITY TYPE:	840
ADDRESS:	16035 LOS GATOS ALMADEN ROAD		TELEPHONE:	(408) 356-3211
CITY:	LOS GATOS	STATE: CA	ZIP CODE:	95032
CAPACITY:	10	CENSUS: 0	DATE:	01/15/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Danna Matthew-Osborn		TIME COMPLETED:	01:00 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 conducted a scheduled Tele-Pre-Licensing inspection via video conference call (FaceTime) with Danna Matthew-Osborn, spouse of Applicant representative. The Facility is applying for a change of ownership from sole proprietorship (Danna Matthew-Osborn) to Peppertree Schools, LLC. The Applicant Representative, Jeffrey Osborn, was not present during today’s Pre-Licensing inspection. The Applicant Representative is applying for a combination center in conjunction with the change of ownership (Preschool #434415603 and School Age #434415604) on the same premises. The existing Facility is currently in operation (Preschool: #430703423) on the same premises. A Fire Clearance was approved by San Jose Fire Department on 12/18/2020. The Preschool Program will operate Monday through Friday from 6:30 AM to 6:00 PM, serving Preschool children ages 2 years to entry into 1^st grade. The School Age Program will be utilizing the following Rooms: Computer Lab, Club House, & Sun Room & Kitchen (3:45 PM to 6 PM) and the The Preschool Program will be utilizing the following Rooms: Classroom 1 & 2, Art Room, Cubby Room, and Sun Room & Kitchen (6:30 AM to 3:30 PM only) The Facility was inspected inside and outside via video conference call (FaceTime). During today’s video conference call, the indoor/outdoor measurements were taken by Danna Matthew-Osborn, director. LPA observed the measuring process and provided direction over the video conference call. Indoor Activity Space: Computer Lab: 10.333 x 14.750 = 152.411 minus (1.333 x 5.083 = 6.775 encumbered space) = 145.636 Club House: 19.250 x 17.333 = 333.660

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2021

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: PEPPERTREE SCHOOLS COTTAGE HOUSE	FACILITY NUMBER: 434415604
	VISIT DATE: 01/15/2021

NARRATIVE

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Sun Room (6:30AM to 3:30 PM):
23.333 x 17.750 = 414.160

Kitchen (6:30 AM to 3:30 PM):
10.500 x 10.500 = 110.250

TOTAL INDOOR ACTIVITY SPACE:1,003.706 sq. ft. divided by 35 = 28 children

The Facility has 2 sinks (30), 2 toilets (30) for children to use. The bathroom for the school age children allows for privacy. The sinks for children do not have hot running water. The Facility will serve only AM and PM snacks. Parents will provide lunch for the children. Children who become ill will use the isolation bathroom and will be isolated in the director’s office area with isolation equipment. Drinking water is available indoors via water bottles & water jugs/individual water cups.

There are 3 tables, 14 chairs, and 20 cubbies for the school age children. The Facility has central heating/air conditioning/ventilation in each Room. All Rooms have appropriate lighting. All Rooms are furnished with age appropriate supplies and toys. There is a separate staff bathroom not utilized by the children which an isolated child can be used if needed.

LPA observed a trash can with tight-fitting lids in each Room. LPA observed the cleaning supplies are kept on high shelves inaccessible to children. LPA observed smoke/carbon monoxide detectors in each Room. First aid supplies, including touchless thermometer, are stored in each Room inaccessible to children. The Facility has a food preparation area that contains a refrigerator, microwave, & hot/cold running water. Danna states that the Facility will utilize disposable plates and utensils. Danna states that the medications will be stored in Director's office.

Incidental Medical Services (IMS) policy was discussed. Danna was provided the information regarding ADA: toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: http://www.ada.gov/childqanda.htm. Danna states that the Facility plans to offer IMS services (inhaler & EpiPen) and an IMS plan is on file.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2021

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: PEPPERTREE SCHOOLS COTTAGE HOUSE	FACILITY NUMBER: 434415604
	VISIT DATE: 01/15/2021

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Jeffrey Osborn, Applicant Representative, and Danna Matthew-Osborn, Applicant Representative's spouse, and Theresa Beckerdite, Director, have obtained Criminal Records Clearances and Child Abuse Index Checks. Danna Matthew-Osborn, director, has met the education and experience qualification requirements. Theresa has valid CPR/First Aid certifications on file (exp: 04/2021) and completed the Preventative Health/Safety Training which includes the Nutrition and Lead Safety component. Theresa has proof of immunity against Measles and Pertussis and opt-out form for the influenza vaccine on file. Theresa Mandated Reporter Training for Child Care Provider Certification expires in November 2022.

LPA reminded Danna of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the facility, 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 up to $500.00 per person. For a subsequent violation within a 12 month period, civil penalty amounts to $100.00 per person up to $3000.00 per person.

Outdoor Activity Space:

Asphalt Play Area: (18.583 x 68.833 = 1,279.123) + (30.083 x 18.167 = 546.517) = 1,825.640 minus (5.000 x 8.750 = 43.750 encumbered space) = 1,781.890
Play Yard: 20.500 x 88.833 = 1,821.076
Grass Yard: (21.000 x 23.500 = 493.500) + (16.000 x 16.000 = 256.000) + (39.333 x 65.750 = 2,586.144) = 3,335.644
Sand Play Area: (40.167 x 90.750 = 3,645.155) + (19.750 x 13.167 = 260.048) = 3,905.203

TOTAL OUTDOOR SPACE: 7,551.919 sq. ft. divided by 75 = 100 children
LPA observed the playground is safe, secure, and surrounded by appropriate fencing. No bodies of water were observed. LPA observed the outdoor activity space is equipped with age-appropriate toys and equipment. Shade is provided by canopies, trees, umbrellas, and building overhangs. The areas around and under the play structures in the Play Yard & Grass Yard are cushioned with material (artificial grass with padding) that absorbs falls. Drinking water is available outdoors via water bottles & water jugs/individual water cups.

LPA advised Danna that due to the current Covid-19 pandemic and "Shelter In Place" Order, the Evaluation Report will be emailed to her (email: danna.osborn@peppertreeschools.com) with "Read Receipt" notification. Danna understands that her reply to the email will serve as acknowledgement that the report was received.

LPA conducted an exit Interview and advised Danna that a license for 10 school age children will be approved upon receipt of the following: 1) Acknowledgement of "receipt" of this report has been received by LPA Matos

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2021

LIC809 (FAS) - (06/04)

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