<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416162
Report Date: 07/24/2019
Date Signed: 07/24/2019 01:12:22 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:HACIENDA HI-FIVE AFTER SCHOOL CLUBFACILITY NUMBER:
434416162
ADMINISTRATOR:MILLER, SARAHFACILITY TYPE:
840
ADDRESS:1290 KIMBERLY DRIVETELEPHONE:
(408) 535-6259
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:70CENSUS: 0DATE:
07/24/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Arulkumar Sundarrraman & Sarah MillerTIME COMPLETED:
01:20 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) Tuoc Doan conducted an announced scheduled Pre-Licensing inspection of the facility. LPA met with the Applicant's Representatives: LLC's Managing Partner Arulkumar Sundarrraman, and Director Sarah Miller.

Applicant LR Sports LLC is applying for a license to operate a School-Age Center in Rooms #4 and #18 at the address listed above. The capacity of each room is 30, bringing the total maximum capacity of the Center to 60. The School-Age Center is located on a functioning school site: Hacienda Environmental Science Magnet School. The Applicant has submitted verification of the school fire inspection conducted on 10/23/18 by the San Jose Fire Department Bureau of Fire Prevention. Fire extinguisher in the rooms were last serviced on 01/2019. The School-Age Center will operate Monday through Friday: 6:45AM to 09:00AM and 03:00PM to 06:30PM serving children from Transitional Kindergarten to Grade 6. Facility maintains telephone service.

Since this School-Age Program will be operating on a functioning school site, the Program is exempt from square-footage requirements for indoor and outdoor activity space, and toilet requirements for child day care centers, pursuant to Health and Safety Code Section 1596.806.

LPA observed that there are two toilets in Room#4, one for female and one for male. There are water fountains inside the rooms and outside. Room #18 also has the same accommodation. Children will also have access to the restrooms, sinks, and water fountains on the school site. The children will be using the Elementary School's field and playground for outdoor activities. The outdoor activity space is enclosed with fencing. Areas under high climbing equipment has material that absorbs falls. Shade is provided by building overhang. Facility has water fountains indoor and outdoor and children will be bringing their own water bottle to ensure that drinking water is available. Furniture and equipment for children to use were observed. There were tables and chairs to accommodate the maximum capacity of children requested. Weapons will not be stored on the premises. The Program will not be providing transportation.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019
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: HACIENDA HI-FIVE AFTER SCHOOL CLUB
FACILITY NUMBER: 434416162
VISIT DATE: 07/24/2019
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
26
27
28
29
30
31
32
Facility will provide an afternoon snack. LPA observed container used for storage of solid wastes has tight-fitting cover on. Detergents, cleaning compounds, sharps, medicines, and other items which could pose a danger if readily available to children were stored where they are inaccessible to children in care. Storage areas have locks. At the end of the day, facility will receive janitorial service provided by the school district.

The Director meets the education qualification requirement and has completed 16 hours of training on preventive health practices, which included pediatric cardiopulmonary resuscitation and pediatric first aid, and one hour on Child Care Nutrition. Director has proof of immunity against Measles and Pertussis, and Health Screening with Tuberculosis test result.

LPA informed the facility that as of today, 07/24/19, only Director Sarah Miller, and LLC's Managing Partners Arulkumar Sundarrraman and Swetha Nadamuni have received Criminal Background and Child Abuse Index Clearance and are associated to the facility Hacienda Hi-Five After School Club. LPA reminded the facility 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 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.

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 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.

Facility is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Annual License fee, Adoption of new Laws, etc.

Exit Interview was conducted, where this report and facility's plan of operation were reviewed with LLC's Managing Partner and Director. Applicant LR Sports LLC was informed that once Licensing Office receives an updated plan of operation, the file will be submitted to Licensing Management for review and final approval.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2