440709549-11-1-2022-07-CC-CNEN-CKRTK3-20221101144715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 440709549
Report Date: 11/01/2022
Date Signed: 11/01/2022 02:47:29 PM

Document Has Been Signed on 11/01/2022 02:47 PM - It Cannot Be Edited

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 PRESCHOOL		FACILITY NUMBER:	440709549
ADMINISTRATOR:	SHIREEN WALKER		FACILITY TYPE:	850
ADDRESS:	445 SUMMIT ROAD		TELEPHONE:	(408) 847-2717
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	30	CENSUS: 6	DATE:	11/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:09 AM
MET WITH:	Kami Pacheco		TIME COMPLETED:	02:57 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), Cortney Nelson, met with Site Director, Kami Pacheco, for an unannounced Required- 1 Year Inspection. LPA was granted access to the facility by the Site Director and toured both indoors and outdoors during the inspection. Upon arrival, there were 6 preschool-age children and 2 staff members present, which is compliant with the facility license capacity and ratio requirements. LPA observed all required postings near the entrance to the facility. Hours of operation are Monday – Friday, 9:00AM-3:00PM and the facility is at Mount Madonna School, located on the lower campus. LPA reviewed sign-in/out sheets, facility roster (LIC9040), and fire/disaster drill log during today’s inspection. Sign-in/out was observed to be completed and LPA advised that signature should be full legal signature and time of day. The Site Director states that some children in the program arrive via bus. Staff pick up the children from the school bus, walk them to the preschool, and sign the children in upon arrival. The last fire/disaster drill was conducted with the school campus on 10/19/2022, which is compliant with the six-month requirement for facilities. LPA observed two fully charged 3A40BC fire extinguishers (last serviced: 9/2022), built in fire alarm system and functioning carbon monoxide detector. Site Director states that she does currently have a child in care who require Incidental Medical Services and does not administer any additional medication at this time. LPA provided PIN 22-02 CCP for review on best practices for IMS at child care centers. The Site Director states that there are no weapons or firearms on the premises. This facility provides Incidental Medical Services- IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Child Care Centers, Section 101173 and 101226. The following information regarding ADA was provided: US Department of Justice 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

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

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: MOUNT MADONNA PRESCHOOL	FACILITY NUMBER: 440709549
	VISIT DATE: 11/01/2022

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
26
27
28
29
30
31
32

Indoor areas of the facility were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. The facility offers Montessori based learning for the children enrolled. During todays inspection, preschool-age children were observed to be participating in circle time, dancing, and stretching in yoga poses with staff. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Drinking water is readily available for children in the facility via water dispensers and water bottles from home labeled with the children’s names. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom, not utilized by the children, which an isolated child can use if necessary. There is a working telephone in the facility. Site Director states that since the pandemic, food is no longer served to the children in care and children bring their own lunch and snacks. Children participate in bread making on Wednesdays at the facility and LPA observed that the kitchen is properly set-up for use.

The outdoor area of the facility was inspected and observed to be fenced in. There are various activities outside for the children such as a garden, sandboxes, and playground equipment. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (tanbark) to absorb falls. No outdoor bodies of water were observed during today’s inspection. LPA advised Site Director on reuse of rain water for the children and advised that standing water should never be accessible to children without proper supervision. Shaded rest area is provided by canopy and building overhang.

3 staff files were reviewed and most required documents were present. There is at least one staff member present with current CPR/First-Aid that expires 8/2023. The Site Director has current Mandated Reporter Training that expires on 6/29/2024. LPA reminded the Site Director that the Mandated Reporter Training must be renewed by all staff every 2 years and to ensure it is for Child Care Providers (AB1207). 5 children’s files were reviewed during today’s inspection and most required documents were present. LPA advised that signed admission agreements should be maintained in children's file.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

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: MOUNT MADONNA PRESCHOOL	FACILITY NUMBER: 440709549
	VISIT DATE: 11/01/2022

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
26
27
28
29
30
31
32

The Site Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

The Site Director understands that she shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. LPA reminded Site Director 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, such as field trips. Site Director states that all staff employed at the school receive training every 2 years.

Exit interview conducted and report was reviewed with the Site Director, Kami Pacheco.

As a result of today’s inspection, deficiencies were cited, see 809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Documents requested: Updated plan of operation/ parent handbook to reflect changes to the program since the pandemic, including changes in food services and summer camp offerings. Also discussed were changes to the facility license to update services through kindergarten and to remove "closed in summer."

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 11/01/2022 02:47 PM - It Cannot Be Edited

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: 11/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the Site Director did not comply with the section cited above for 2 out of 3 staff present, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/11/2022
	Plan of Correction
1 2 3 4	The Site Director will submit proof of immunizations for tDap, MMR, and flu (or signed declination) for S1 & S2 by 11/11/2022. LPA advised that this requirement is for all staff, including subs who may be present at the facility.

Type B

Section Cited

CCR

101221(a)

Child's Records

(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the Site Director did not comply with the section cited above for 3 out of 5 children files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/11/2022
	Plan of Correction
1 2 3 4	The Site Director will submit missing documents for children's files by 11/11/2022. LPA provided copy of LIC811 indicating documents missing for C1, C2, & C3.

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4