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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440709549
Report Date: 09/11/2019
Date Signed: 09/11/2019 11:39:48 AM

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:MOUNT MADONNA PRESCHOOLFACILITY NUMBER:
440709549
ADMINISTRATOR:SHIREEN WALKERFACILITY TYPE:
850
ADDRESS:445 SUMMIT ROADTELEPHONE:
(408) 847-2717
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:30CENSUS: 17DATE:
09/11/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kami PachecoTIME COMPLETED:
11:45 AM
NARRATIVE
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LPA, Behbood made a visit to conduct an annual/Random visit. Met Michelle Fisher, Teacher at the classroom who inform analyst that Shireen, Site Director with 17 children and parent volunteer are out hiking, they arrived during visit. Also met Kami Pacheco, Director of entire campus including preschool. Inside and play ground was toured. Random Staff and children files were reviewed. Children's file contains Emergency information, immunization and consent to provide emergency medical treatment Staff files contains their transcripts, and immunization records.
All staff have clearances on Licensing system. Ms. Walker understands that all staff must have a clearance associated to the facility before they can be present. Failure to do so will result in a fine.
There are no bodies of water at the facility. Ms. Walker states there are no weapons at the Preschool.
Cleaning supplies are stored inaccessible to children.
Furniture & equipment appear in good condition. Floors appear clean. Children's bathrooms are in operating condition.
Preschool refrigerator appears clean & all food is covered. Trash can for food waste has a tight fitting cover.
Children bring lunch from home and facility provides 2 snacks, menu is posted. .
Playground has climbing structures, gravel; and wood chips are used for cushioning material. Discussed with director was the need to periodically redistribute the cushioning material under the slide and to cover the cups to ensure dust and other particles doesn't get into cups when outside.
Drinking water inside the classrooms and the playground are provided via water jug.
Children were supervised during the visit.

Please see next page for citation under Title 22.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2019
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: MOUNT MADONNA PRESCHOOL
FACILITY NUMBER: 440709549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2019
Section Cited

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Teacher- Child Ratio - Whenever children are engaged in activities away from the center, no teacher shall be in charge of a group of more than 12 children. 17 children were out hiking with one teacher and a parent volunteer. This is potentially dangerous to health and safety of children.
Type B
09/20/2019
Section Cited

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Health and Safety - Mandated Child Abuse Reporter Training- One staff hasn't not completed the mandated child abuse training. This is potentially dangerous to health

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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2019
LIC809 (FAS) - (06/04)
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