434416695-10-26-2020-07-CC-DMAC-BURVAU-20201026161632

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416695
Report Date: 10/15/2020
Date Signed: 10/26/2020 04:16:37 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:	LITTLE OAK NURSERY		FACILITY NUMBER:	434416695
ADMINISTRATOR:	ANNIE CHOU		FACILITY TYPE:	830
ADDRESS:	1921 CLARINDA WAY		TELEPHONE:	(408) 396-1252
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	30	CENSUS: 6	DATE:	10/15/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Annie Chou		TIME COMPLETED:	05:00 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) Dung Mac conducted a scheduled Tele-Pre-Licensing inspection via video conference call (FaceTime) with Annie Chou, Applicant Representative. The Applicant Representative is applying for a combination center (Infant #434416695 and Preschool #434416693) on the same premises. The existing facility is under Kimberly Gresham Burt (facility #434406697). A Fire Clearance was approved by San Jose Fire Department on 9/30/2020. The Infant Center will operate Monday through Friday from 08:00AM to 04:30PM, serving Infant children ages 0-24 months. The Infant program will be utilizing Rooms 8, 9, and 32 and the Preschool program will be using Rooms 6, 7, 22, 29, 30, 31, and Art Room. The facility was inspected inside and outside via video conference call (FaceTime). During today’s video conference call, the indoor/outdoor measurements were taken by Applicant Representative, Annie Chou, and Administrator, Erica Lin, as LPA observed the measuring process and provided direction over the video conference call. Indoor Activity Space: Room # 8: (21.258 x 31.983 = 679.894) – (396.954 encumbered space) = 282.940 Room # 9: (21.258 x 31.983 = 679.894) – (396.954 encumbered space) = 282.940 Room # 32: (31.300 x 26.808 =839.090) + (9.916 x 5.583 = 55.361) = 894.451 (Total sq. ft.) – (Total Encumbered Space) = 894.451 - 48.879 = 845.572 *TOTAL INDOOR ACTIVITY SPACE:* 1,411.372 *sq. ft. divided by 35 sq. ft / child = 40 Infants* Report continued on Page 2

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

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: LITTLE OAK NURSERY	FACILITY NUMBER: 434416695
	VISIT DATE: 10/15/2020

NARRATIVE

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Report continued from Page #1

Annie states that the Infant program will not offer potty training. LPA observed a changing table that is not within an arm's reach of a sink in each room. LPA observed a trash can with a tight fitting lid for diapers disposal and solid waste containers with tight-fitting lids in each room. LPA observed the cleaning supplies are kept on high shelves inaccessible to children. LPA observed smoke/carbon monoxide detectors in each room. First aid supplies are stored in each classroom inaccessible to children. Annie states that the medications will be stored in Director's office.

LPA observed refrigerator, microwave, and bottle warmers in each room. There are highchairs as infant children will be held while feeding until they are able to sit unassisted in a chair. Feeding chairs and other appropriate seating equipment will be used to seat infants during feeding. Annie understands that infants shall be held during feedings if they are unable to sit unassisted. Annie also understands that propped bottles are not permitted. Annie understands that the Needs and Service Plan needs to be updated at least once every 3 months. Annie understands that a baby walker or any similar items shall not be used on the premise of a child day care facility.

There are 3 tables, 15 chairs, 17 cribs, and 10 cots for the children. Infants that do not require cribs will nap on cots. There are cubbies and hooks for children to store their belongings. LPA reminded Annie that each crib or cot shall be occupied by only one infant at a time and each infant's bedding shall be used for him/her only. Such bedding shall be replaced when wet or soiled. Classrooms are furnished with age appropriate toys. There is a separate staff bathroom not utilized by the children which an isolated child can be used if needed.

Facility has 14 sinks (210), 10 toilets (150), and 3 urinals (45) for children to use. The sinks used by children only have cold running water. Annie states that parents will provide formula, baby food, and diapers. Facility will serve only AM and PM snacks. Drinking water is available indoors via pitcher/cups. Disposable dishes and utensils will be provided.

Annie Chou, Applicant Representative, and Jennifer Potmesil, Director, have obtained a Criminal Records Clearance and Child Abuse Index Checks. Director has met the education and experience qualification requirement. Director is enrolled to take First Aid/CPR on October 24, 2020 17. Proof of completion of Preventative Health Practices is on file; however, Director needs to retake Health & Safety training to include Nutrition and Lead Poisoning Prevention component. Director has proof of immunity against Measles and Pertussis, Influenza on file. Director's Mandated Reporter Training for Child Care Provider Certification expires 10/08/2021.

Report continued on Page #3

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

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: LITTLE OAK NURSERY	FACILITY NUMBER: 434416695
	VISIT DATE: 10/15/2020

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LPA reminded the Applicant Representative of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the facility, 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.

Infant playground (portion of playground 1) : 20.375 x 88.350 = 1,800.131

TOTAL OUTDOOR SPACE: 1,800.131 sq. ft. divided by 75 = 24 children

Infant playground has space for 24 Infants. There is not enough space for the requested Infant capacity of 30. As a result, a waiver for playground space will be requested by the Applicant Representative.

LPA observed the playground is surrounded by appropriate fencing. No bodies of water were observed. LPA observed the outdoor activity space is equipped with age-appropriate toys and equipment. Shade is provided by canopies and building overhangs. Drinking water is available for outdoors via pitcher/cups.

LPA advised Annie that due to the current Covid-19 pandemic and "Shelter In Place" Order, the Evaluation Report will be emailed to her (email: annie.littleoak@gmail.com) with "Read Receipt" notification. Annie understands that her reply to the email will serve as acknowledgement that the report was received.

LPA conducted an exit Interview and advised Annie that a license for 30 Infant children will be submitted for the final stage of review by Licensing Management upon the receipt of the following:
1) A waiver request along with staggered schedules for the playground space.
2) Photos of changing table is within an arm's reach of the sink.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC809 (FAS) - (06/04)

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