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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274416181
Report Date: 06/26/2024
Date Signed: 06/27/2024 09:04:30 AM

Document Has Been Signed on 06/27/2024 09:04 AM - 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:POTRERO CANYON SCHOOL LLCFACILITY NUMBER:
274416181
ADMINISTRATOR/
DIRECTOR:		ANDRA BRIANTFACILITY TYPE:
850
ADDRESS:5716 CARMEL VALLEY ROADTELEPHONE:
8316250545
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 16DATE:
06/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Andra BriantTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Andrea Cortez and AGPA Joe Macias conducted an unannounced Required - 1 Year Inspection (care tool). The purpose of today’s visit is to ensure the facility is in compliance with Title 22 California Code of Regulations. LPA met with the Licensee/ Director Andra Briant, and explained the nature of today's inspection. Today census is 16. The center is located on the Congregation Beth Israel grounds in classrooms 1, 2, 3, and 4. The Congregation Beth Israel grounds also house an adult day program, Paradigm Adult Day Program #275202010. The two programs shall not commingle. LPA toured the Facility both inside and outside during todays visit. LPA 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), and Activity Schedule. The hours of operation are Monday - Friday, 8:30am - 3:30pm.

LPA reviewed six children's and four staff files during today's visit. Each child's file reviewed contains the Information and Emergency Information form (LIC 700), immunization records, physicians report, personal rights, and parents rights. All staff files contain the required transcripts/verification of experience. All staff's CPR and First Aid certifications are current. 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 (field trips).

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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: POTRERO CANYON SCHOOL LLC
FACILITY NUMBER: 274416181
VISIT DATE: 06/26/2024
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Director understands the conditions, limitations, and capacity specifications of the Facility license. Director understands that children shall be visually supervised at all times. LPA observed that all rooms are in order. Drinking water is readily available for the children in each room and in the outdoor playground area via water pitcher, and water bottles. LPA observed solid waste containers with tight-fitting lids in each room. Staff and children's bathrooms are clean, sanitary. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Director states that there are no weapons or firearms on the premises.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by children is surrounded by appropriate fencing. LPA observed that the outdoor equipment is age appropriate. LPA did not observe any bodies of water.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food is provided by the parents. Cleaning supplies are securely stored and inaccessible to the children. LPA observed a fully charged 2A10BC fire extinguisher, and working smoke/carbon monoxide detectors. Director states that the Facility does not administer medications at this time.


The Licensee/ Director Andra Briant 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.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
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: POTRERO CANYON SCHOOL LLC
FACILITY NUMBER: 274416181
VISIT DATE: 06/26/2024
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Incidental Medical Services (IMS) policy was discussed. 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

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.

No deficiencies cited, exit interview conducted and report was reviewed with the Licensee/ Director Andra Briant.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC809 (FAS) - (06/04)
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