434416139-5-17-2022-07-CC-PHEZ-CEHQG6-20220517120901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416139
Report Date: 05/17/2022
Date Signed: 05/17/2022 12:09:12 PM

Document Has Been Signed on 05/17/2022 12:09 PM - It Cannot Be Edited

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 CENTER		FACILITY NUMBER:	434416139
ADMINISTRATOR:	SORA KIM		FACILITY TYPE:	830
ADDRESS:	3124 WILLIAMSBURG DRIVE		TELEPHONE:	(510) 508-5619
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	12	CENSUS: 5	DATE:	05/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Sora Kim		TIME COMPLETED:	11:28 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 Analysts (LPA) Pete Hernandez conducted an unannounced, Required 1 Year inspection, met with the Infant Program Director, Sora Kim , and explained the nature of today's inspection. The following ratios in the, currently used, infant rooms during time of inspection Infant Room 2: 1 Teacher and 1 Assistant / 5 infants Infant Room 1: No occupants. The facility was in compliance with teacher/infant ratios, children were not left unattended and were constantly under the direct visual supervision of a staff person. LPA noted the staff and infants were interacting in various activities. Normal Business hours Monday - Friday 8:30 AM to 6:00 PM. LPA completed a physical plant inspection touring the building inside and out. No bodies of water were found. Director stated that there are no weapons stored in the facility. Disinfectants, cleaning solutions, poisons, and other items that are dangerous to infants were locked up and inaccessible. Furniture and equipment was in good condition, free of sharp, loose, or pointed parts. Facility has age appropriate furniture and equipment, including cribs, mats, feeding chairs, and changing tables. Infant changing tables are located within arms reach of a sink. No baby walkers or bouncers were witnessed during the inspection. All storage containers for solid waste had tight fitting covers and were in good repair. Facility was free of flies, other insects, and rodents. Facility has adequate indoor activity space for infants that is physically separate from space used by the preschool child care center. Bottles, dishes, and containers of food brought by the infant's authorized representative are labeled with the infant's name and current date. Facility has at least one functioning carbon monoxide detector that meets statutory requirements. Last fire drill log entry was on 3/10/22. Facility has adequate outdoor activity space and play equipment that is maintained in a safe condition and is free of hazards. Facility maintains a kitchen for school children. Continued on Page #2. Report dated 5/17/2022

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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: BLUEBIRD MONTESSORI CHILD CARE CENTER	FACILITY NUMBER: 434416139
	VISIT DATE: 05/17/2022

NARRATIVE

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LPA reviewed safe sleep policies for the infants with the Director LPA also discussed the responsibility for providing care and supervision for infants while napping including the need for a staff member to be present when there is an infant napping. There were no infants napping at the time of inspection. LPA gave copy of Safe Sleep Information Flyer and a copy of the LIC 9227 Individual Infant Sleeping Plan as it relates to infants.

The outdoor activity area is surrounded by appropriate fencing. The play structure and equipment outside were age appropriate in good condition. Areas around play structure were cushioned with resilient materials. Shaded rest areas are provided by canopy. LPA did not observe any bodies of water.

All Staff were fingerprinted and associated 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.

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 a copy obtained.

LPA Hernandez reviewed the files of 1 Teacher and 6 infants. All or the required documentation was available in the file.

All Infants had current Infant Care Plans. Licensee also had current Needs and Services plans for all the infants.

Continued on Page #3 of Report dated 05/17/2022

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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: BLUEBIRD MONTESSORI CHILD CARE CENTER	FACILITY NUMBER: 434416139
	VISIT DATE: 05/17/2022

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This facility provides 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 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

Licensee understands that there needs to be at least one Staff pesent at all times with a current CPR / First Aid certificate. Licensee's CPR / First Aid expires on 8/25/23.

TYPE A language: SHOULD THERE EVER BE AN ISSUANCE of Type A citations today, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with the Licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Sora Kim, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

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