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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444403585
Report Date: 12/20/2023
Date Signed: 12/20/2023 02:34:58 PM


Document Has Been Signed on 12/20/2023 02:34 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:GREEN ACRES STATE PRESCHOOLFACILITY NUMBER:
444403585
ADMINISTRATOR:MELANIE SLUGGETTFACILITY TYPE:
850
ADDRESS:984-5 BOSTWICK LANETELEPHONE:
(831) 462-1116
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:56CENSUS: 18DATE:
12/20/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Donna GeffkenTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Jessica Bongardt and Anna Morales met with Donna Geffken, Director, for an unannounced Required - 3 Year inspection. LPA toured the indoor and outdoor areas of the Facility during today's inspection. LPAs observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus, and Activity Schedule. Days and hours of operation are Monday to Friday 7:30AM-4:30PM. The facility is licensed to serve a maximum of 56 children.

LPAs reviewed seven children's and four staff files during today's inspection. All staff files reviewed did have current Mandated Reporter Certificates on file. There is at least one staff has current CPR and First Aid certifications on file. The director understands 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. Smoke detectors and carbon monoxide alarms were observed in the classroom along with a fully charged fire extinguisher. Last fire/disaster drill was completed on 11/13/2023.

LPAs observed that the teacher/child ratio was in compliance during today's inspection. LPAs observed 18 children and 4 teachers during today's inspection. The director understands the conditions, limitations, and capacity specifications of the Facility license. The Director understands that children shall be always visually supervised. If a child comes to the facility who exhibit symptoms of illness including, but not limited to, fever or vomiting,they are not accepted into care. Any children who become ill during the day, shall be isolated in the main office area until they are picked up.

Director understands that children's personal rights should not be violated, including no unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510)-566-5850
LICENSING EVALUATOR NAME: Jessica BongardtTELEPHONE: 408-834-2558
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GREEN ACRES STATE PRESCHOOL
FACILITY NUMBER: 444403585
VISIT DATE: 12/20/2023
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LPAs observed that the Facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. The Director states that the Facility has the school janitorial services who come and clean the classrooms. The Director understands that the Facility must be kept free of flies and other insects & rodents. LPAs observed that all furniture and equipment is in good condition and safe for the children. Drinking water is made available by a water cooler inside the classroom and personal water bottles that are labeled for each child.

LPAs observed there is hot and cold running water, refrigerator, and microwave on the premises. The Facility provides all meals for the children (AM/PM snack, breakfast, and lunch).. The Facility has trash cans with tight fitting lids for solid waste in the classroom. Cleaning supplies are inaccessible to the children and stored in cabinets located in areas off limits to children. LPAs observed a complete first aid kit available in the facility with touch-less thermometers..

The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPAs observed that the outdoor equipment is age appropriate and in good condition. Shade rest areas are provided by trees and a canopy area. There is sufficient resilient materials on the outdoor playground area. LPAs did not observe any bodies of water. Director states that the Facility does not provide transportation for preschool children.


This facility does provide Incidental Medical Services (IMS) at this time. 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
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510)-566-5850
LICENSING EVALUATOR NAME: Jessica BongardtTELEPHONE: 408-834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GREEN ACRES STATE PRESCHOOL
FACILITY NUMBER: 444403585
VISIT DATE: 12/20/2023
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Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.
For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

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/inspection-process

LPAs provided Director with website resources on managing food allergies at school and handling medical emergencies related to food allergies. CDC Managing Food Allergies at School

https://www.cdc.gov/healthyschools/foodallergies/index.htm

American Academy of Pediatrics Healthy Children Medical Emergencies

https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/When-to-Call-Emergency-Medical-Services-EMS.aspx

Exit interview conducted and report was reviewed with Donna Geffken, Director. Deficiencies were cited and appeal rights given to Director during today's inspection.



A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510)-566-5850
LICENSING EVALUATOR NAME: Jessica BongardtTELEPHONE: 408-834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/20/2023 02:34 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: GREEN ACRES STATE PRESCHOOL
FACILITY NUMBER: 444403585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2024
Plan of Correction
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Licensee will have the Lead Water test completed or scheduled by this date
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
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
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Licensee will get immunization records to the department by this date for staff 2 and staff 4
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: Gladys KuizonTELEPHONE: (510)-566-5850
LICENSING EVALUATOR NAME: Jessica BongardtTELEPHONE: 408-834-2558
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4