434416186-9-7-2021-07-CC-MMOO-C6MV4B-20210907160605

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416186
Report Date: 09/07/2021
Date Signed: 09/07/2021 04:06:12 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 START		FACILITY NUMBER:	434416186
ADMINISTRATOR:	CEJA, CRYSTAL		FACILITY TYPE:	850
ADDRESS:	4 WABASH AVENUE		TELEPHONE:	(669) 212-8443
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	47	CENSUS: 16	DATE:	09/07/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:03 PM
MET WITH:	Crystal Ceja		TIME COMPLETED:	04:20 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	#2 Licensing Program Analysts (LPAs) Marilou Monico and Dung Mac conducted an unannounced Required - 1 Year inspection. LPAs met with Site Supervisor/teacher, Crystal Ceja, and explained the purpose of today's inspection. Facility's License, Notification of Parents’ Right Poster, Child Car Seat Law, Personal Rights (LIC 613A), Emergency Disaster Plan, and Earthquake Preparedness Checklist were observed to be posted. The center is open Monday through Friday from 08:00 AM to 3:00 PM. Age serve is 2.9 years to entry into kindergarten. The preschool program is licensed in Rooms 1 and 2. LPAs toured the facility both indoor and outdoor. The classrooms, restrooms, and storage areas were inspected. LPAs observed that the facility was operating in compliance with teacher to children ratio requirement. There were no bodies of water observed. Per Site Supervisor, there were no weapons on the premises. Furniture and equipment were observed to be age appropriate and in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, and other items that are dangerous to children were stored inaccessible to children. Restrooms for children to use were observed to be in operating conditions. Floors were clean. Outdoor activity space is enclosed by fencing and is observed to be free of hazards. LPAs observed play equipment were in good condition and areas around the climbing structure have resilient material. Drinking water was readily available to children indoor and outdoor. Activities schedule and Menus were posted. Facility provides breakfast and lunch and are prepared at Luther Burbank Elementary School cafeteria. Trash cans for solid waste had tight-fitting covers on, and were in good repair. LPAs observed working smoke detectors and functioning carbon monoxide detector. Continuation on next page:

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021

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: LUTHER BURBANK HEAD START	FACILITY NUMBER: 434416186
	VISIT DATE: 09/07/2021

NARRATIVE

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This facility provides Incidental Medical Services - IMS. LPAs reviewed storage of medication and equipment/supplies, and reviewed children's, personnel, and administrative records.

LPAs reviewed sign in and out. Six children and six staff files were reviewed during today's inspection. LPAs obtained a copy of children's roster. LPAs reminded Site Supervisor that the online AB1207 Mandated Reported Training needs to be renewed every two years. All of the staff present during the inspection have current certifications in Pediatric CPR and First Aid.

Fingerprint clearances for individuals at this facility who require caregiver background checks are issued by the Santa Clara County Department of Education and do not come under the jurisdiction of Community Care Licensing division.

As a result of this inspection, there were no deficiencies cited.

A copy of this report was provided to the facility at the conclusion of the inspection.

NOTICE OF SITE VISIT WAS ISSUED. SITE SUPERVISOR WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021

LIC809 (FAS) - (06/04)

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