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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416162
Report Date: 10/07/2021
Date Signed: 10/07/2021 12:59:14 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) 568-3674
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:60CENSUS: 21DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Julianna Silva & Arul SundarramanTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ofelia Calivo and Marilou Monico met with Julianna Silva, Director, and Licensee Representative, Arul Sundarraman, for an unannounced Required 1-year inspection. LPAs toured both indoor and outdoor areas of the facility during today’s inspection. The School-Age program is licensed in Rooms #4 and #18 and located in a functioning school site: Hacienda Environmental Science Magnet School. The School-Age program operates Monday through Friday: 6:45 AM to 9:00AM and 3:00PM to 6:30PM, serving children from Transitional Kindergarten to Grade 6. During school breaks and summer break, the facility is open from 7:00 AM to 6:00 PM.

LPAs observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents’ Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Care Car Seat Law (PUB 269), Menus, and Activity Schedule.

A review of Staff records on October 7, 2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPAs reminded Julianna 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 violations within a 12-month period.

LPAs reviewed ten random children's and three staff files (1 Director, 1 teacher, and 1 teacher's aide) during today's inspection. There is at least one staff in the facility with current CPR and First Aid certifications on file. Julianna understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips).

Continuation on next page:
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Ofelia CalivoTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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 4
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: 10/07/2021
NARRATIVE
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LPAs observed that the facility is in compliance with teacher/child ratio requirement. Julianna understands the conditions, limitations, and capacity specifications of the Facility license. Julianna understands that children shall be visually supervised at all times. There were 21 School-Age children present during today's inspection. Julianna is aware of the required sign in and sign out procedures for school age children who arrive on their own. Julianna states that all school age children are picked up by their parent(s)/guardian(s) and no children are allowed to leave the Facility on their own.

LPAs observed that there are stains on the carpet in room #18. LPAs observed that the trash can in Room 18 containing solid waste has a tight-fitting cover however, the cover has large hole in the middle. Julianna states that the Facility receives janitorial services provided by the school district. Julianna understands that the Facility must be kept free of flies and other insects & rodents. LPAs observed that all furniture and equipment is in good condition and safe for the children. Drinking water is readily available for the children in each room and in the outdoor playground areas via water fountains and children are bringing their own water bottle. Staff and children's bathrooms are clean, sanitary, and operable. The children are using the Elementary School’s field and playground for outdoor activities. The outdoor activity areas are enclosed with fencing. Areas under high climbing equipment has material that absorbs falls. Shade is provided by building overhang and outdoor patio.

There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Julianna states that there are no weapons or firearms on the premises. LPAs observed there are no bodies of water in the facility. The Facility has functioning carbon monoxide and smoke detectors.

The facility is providing afternoon snacks. The food preparation and storage areas are clean, free of litter and rubbish, and free of rodents and other vermin. Cleaning supplies are inaccessible to the children and stored in high cabinets & locked lower storage cabinets inaccessible to children.

LPAs conducted an exit interview with Julianna and Arul prior to the conclusion of today's inspection and advised them of the deficiencies issued during today's inspection.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Ofelia CalivoTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2021
Section Cited

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Fixtures, Furniture, Equipment and Supplies - Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents.
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This requirement is not met as evidenced by: LPAs observed that the trash can containing solid waste in Room 18 has a tight fitting cover, however, the cover has a large hole in the middle. This poses a potential risk to the health and safety of the children in care.
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Type B
10/14/2021
Section Cited

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Indoor Activity Space - Indoor Activity Space - The floors of all rooms shall have a surface that is safe and clean.
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This requirement is not met as evidenced by: LPAs observed stains on the carpet in Room 18. This poses a potential risk to the health and safety of the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Ofelia CalivoTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2021
Section Cited

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Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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This requirement is not met as evidenced by: Per record review, Staff #3 is missing immunization in measles, pertussis, and flu in the file. This poses a potential risk to the health and safety of the children in care.
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Type B
11/08/2021
Section Cited

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Personnel Requirements - All personnel, including the licensee, administrator and volunteers, shall be in good health and shall be physically and mentally capable of performing assigned tasks.
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This requirement is not met as evidenced by: Per record review, Staff #2 & #3 are missing health screening with TB test in their files. This poses a potential risk to the health and safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Ofelia CalivoTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4