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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416186
Report Date: 08/23/2019
Date Signed: 08/23/2019 12:24:31 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:LUTHER BURBANK HEAD STARTFACILITY NUMBER:
434416186
ADMINISTRATOR:EMMA MONICAFACILITY TYPE:
850
ADDRESS:4 WABASH AVENUETELEPHONE:
(408) 387-0437
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:72CENSUS: 0DATE:
08/23/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Emma Monica & Renee GarciaTIME COMPLETED:
12:35 PM
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Licensing Program Analysts (LPAs), Marilou Monico, and Dung Mac, met with Applicant Representative, Emma Monica, and Preschool Supervisor, Renee Garcia, for a prelicensing inspection. The center is located at the elementary school site of Luther Burbank. The center will be operating Monday thru Friday from 8 AM to 3 PM. LPAs toured the facility both inside and out, reviewed documents, as well as measured the space available for the children. Indoor measurements are as follows:

ROOM 1 (28): 39.167 x 23.167 = 907.381 minus 83.299 (encumbered space) = 824.082
ROOM 2 (27): 39.167 x 23.167 = 907.381 minus 83.299 (encumbered space) = 824.082
TOTAL PRESCHOOL INDOOR SPACE: 1,648.164 sq. ft. divided by 35 = 47 children

There are 7 sinks (105), 8 toilets (120), and 3 urinals (45), available for the children. There are 60 chairs, 10 tables, 72 cubbies, and 40 cots. Some of the children will be coming on a part time basis and will not nap at the center.

Only cold water is available in the children's sinks. Staff bathrooms are located on the next buildings (Business Office & Luther Burbank Elementary Office). The sick child will use the staff bathroom located in the Business Office if needed and will be accompanied by a staff member. The sick child will be isolated in the Director's Office and isolation equipment will be provided. First Aid supplies are available in each room inaccessible to the children. The center will be administering medication and will be stored in a locked cabinet in each room. The center will be providing breakfast, lunch, morning and afternoon snacks and will be delivered to the center from the cafeteria located on-site. The cafeteria is equipped with refrigerators, freezers, oven, stove, food warmer, and a sink with hot and cold running water. Sanitation is by the dishwasher. There are trash cans with tight fitting covers throughout the facility for the disposal of solid waster. Cleaning products, sharp, objects, and other similar items are stored in a locked cabinet in each room. LPAs observed at least one functioning carbon monoxide detector at the facility. Applicant Representative states there are no weapons on the premises. Drinking water indoor is via water dispenser and disposable cups.

(REPORT CONTINUED ON THE FOLLOWING PAGES (PAGES #2 & #3 - REPORT DATED 08/23/19):
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
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 3
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: LUTHER BURBANK HEAD START
FACILITY NUMBER: 434416186
VISIT DATE: 08/23/2019
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CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 08/23/19):

Fingerprint clearances for individuals working at the facility are issued by the Santa Clara Department of Education and do not come under the jurisdiction of Community Care Licensing Division.

Applicant Representative submitted a revised application during the inspection requesting a capacity of 47 instead of 72 children.

The following items must be completed prior to licensure of 47 children:
1) Approved fire clearance for 47 children.
2) Waiver approval for the playground.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: LUTHER BURBANK HEAD START
FACILITY NUMBER: 434416186
VISIT DATE: 08/23/2019
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 08/23/19):

Outdoor measurements are as follows:
PRESCHOOL PLAYGROUND
123.000 x 99.417 = 12,228.291 minus 367.243 (encumbered space) = 11,861.048
TOTAL OUTDOOR SPACE: 11,861.048 sq. ft. divided by 75 = 158 children

The playground is surrounded by appropriate fencing and the outdoor surfaces are safe. Shade is provided by trees and building overhang. There is a climbing structure in the playground with tanbarks as resilient material. The preschool children will be sharing the playground with the Luther Burbank Elementary School kindergarten at different times. Applicant Representative submitted waiver request and playground schedule during the inspection. Drinking water outdoor is via water jug and disposable cups. The center will not provide transportation for the children. There is a working telephone at the facility which is (669) 212-8443.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated 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. The center will be providing IMS and Plan of Operation on Incidental Medical Services was submitted to Licensing.

LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years. AB 633 was discussed with Applicant Representative. Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.



Beginning January 1, 2019 AB 2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility.

(REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 08/23/19):
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3