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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416139
Report Date: 05/10/2019
Date Signed: 05/10/2019 12:59:09 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:BLUEBIRD MONTESSORI CHILD CARE CENTERFACILITY NUMBER:
434416139
ADMINISTRATOR:SORA KIMFACILITY TYPE:
830
ADDRESS:3124 WILLIAMSBURG DRIVETELEPHONE:
(510) 508-5619
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:12CENSUS: 0DATE:
05/10/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sora KimTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs), Shannel Reed and Marilou Monico, met with Owner/Director Sora Kim for a pre-licensing inspection of the Infant Program. LPAs toured the indoor and outdoor, on limit and off limit areas as well as measured the space available for the children.
Indoor measurements are as follows:
Infant Room 1: 21.667 x 14.833=321.386 minus 31.538= 289.848
Infant Room 2: 21.917 x 20.833 = 456.596 minus= 13.303= 443.293
TOTAL SPACE: 773.141 Divided by 35 (SQ. FEET) EQUALS 20

There are 2 sinks (30) and 2 changing tables within arm’s reach of the sinks, 5 tables, 13 chairs and 29 cubbies available for the children. One of the changing table’s pads measured to half an inch thick. Applicant will replace the padding on this changing table with a pad that measures to at least 1 inch thick. Cold water is available in the children's sinks. There is a staff bathroom located in the Preschool Activity Room. Sick children will be isolated in the Director's Office and isolation equipment will be provided. Isolation bathroom is located in the Preschool Activity Room. The center will provide AM/ PM snacks and lunch prepared from the onsite kitchen. The kitchen is equipped with a stove, oven, hot and cold running water, two refrigerators, microwave oven, and dishwasher. Sanitization will be done by the dishwasher. LPAs observed trash cans with tight fitting covers for the disposal of solid waste. Drinking water indoors will be available via water pitchers, personal water bottles/ sippy cups and disposable cups. There are functioning smoke and carbon monoxide detectors at the facility.

Outdoor Measurements:
Infant Playground 1: 18.667 x 23.583 = 440.223 = 440.223
Infant Playground 2: 41.500 x 12.00= 498.00 minus 18.00 = 480.00
TOTAL SPACE: 920.223 Divided by 75 (SQ. FEET) EQUALS 12

(Facility Evaluation Report dated 05/10/19 is continued on the following page):
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Shannel ReedTELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
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 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: BLUEBIRD MONTESSORI CHILD CARE CENTER
FACILITY NUMBER: 434416139
VISIT DATE: 05/10/2019
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(Facility Evaluation Report dated 05/10/19 is continued from the previous page):
The playground areas are surrounded by appropriate fencing and the outdoor surfaces are safe. More resilient material is needed under the play equipment in playground 1. Shade is provided by two canopies. Drinking water outdoor available via water pitchers, personal water bottles/ sippy cups and disposable cups. The center will not provide transportation. There is a working telephone which is (510) 508-5619.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A Plan of Operation that includes IMS has been 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. Medication will be stored in a locked drawer in the Director’s Office.

A review of staff records during today's visit indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded the Directors 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. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period.



LPAs discussed Parent Notification Requirements (AB 633) and provided Owner/ Director with the Lead Safety information sheet (AB 2370).

The following items must be completed prior to licensure of 12 children in the Infant program:


1) Replacement of the changing table pad with a pad that measures to 1 inch thick.
2) More resilient material on Infant Playground 1.
3) Repair of the foundation under the resilient material on Infant Playground 2.
4) Licensing Program Manager's review and approval.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Shannel ReedTELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2