<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274418512
Report Date: 06/12/2026
Date Signed: 06/12/2026 12:53:19 PM

Document Has Been Signed on 06/12/2026 12:53 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:PGUSD STATE PRESCHOOLFACILITY NUMBER:
274418512
ADMINISTRATOR/
DIRECTOR:
ABBIE ARBRUNFACILITY TYPE:
860
ADDRESS:1065 CONGRESS AVENUETELEPHONE:
(831) 646-6560
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY: 20TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/12/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:Abbie ArbrunTIME VISIT/
INSPECTION COMPLETED:
01:30 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
On 06/12/26, Licensing Program Analyst (LPA) Janette Cruz met with Abbie Arbrun, Applicant representative. The purpose of the visit was an announced pre-licensing inspection at the facility to ensure the health, safety and personal rights as required by Title 22 and Health and Safety Regulations governing California Child Care Centers will be met. This is an application for a change of location for total of 20 preschool children ages 3 - 5 years in Room K-3. Facility is currently operating under facility number 274413124. Facility will be issued a single license upon completion of this application process. The childcare center will operate Monday–Friday 8:55 AM - 1:55 PM. The fire clearance was approved on 05/06/2026. No children were present at the facility during today’s inspection. Facility is located on the premises of an elementary school : Forest Grove Elementary.

LPA toured and measured the on-limits areas and classroom space at the facility. The facility consists of one classroom.
Preschool Classroom measurements are:
The Indoor total measurements contain a total of {1155.96} square feet, which will accommodate Applicant’s request for 20 preschool children.
Preschool Outdoor Play measurements are:
Outdoor total measurements contain a total of {15937.50} square feet, which will accommodate Applicant’s request for 20 preschool children.

Applicant stated that the preschool outdoor activity space will be shared with school-age children enrolled at Forest Grove Elementary School at different times throughout the day. Applicant shall submit a waiver request for the shared use of the preschool outdoor activity space with other programs.

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Janette Cruz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2026
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
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: PGUSD STATE PRESCHOOL
FACILITY NUMBER: 274418512
VISIT DATE: 06/12/2026
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
LPA observed the classroom to be clean, safe, sanitary, and in good repair. A comfortable temperature for children was maintained throughout the facility. All materials and surfaces accessible to children, including toys, were free of toxic substances. Play equipment and learning materials were age-appropriate and in a safe operating condition. The preschool classroom is furnished with 30 chairs, 5 tables, 24 cubbies, 20 cots, 3 sinks and 2 toilets to accommodate the children in care.

Applicant informed LPA that the preschool children will be commingled with children enrolled in the Special Education program as part of the school district's inclusion model. LPA advised that appropriate supervision and required staff to child ratios must be maintained at all times. LPA further advised that children enrolled in the Special Education program may not be counted toward the licensed preschool capacity or ratio requirements.

Staff have a designated restroom separate from the children’s restrooms, which may also be utilized for sick children if needed. Sick children will be isolated in the nurse's office located at the facility office. First aid supplies, medications, and cleaning products are stored in high cabinets and locked areas, out of children’s reach. LPA advised Applicant that all containers used for storage of solid wastes, including moveable bins, shall have a tight-fitting cover that is kept on; shall be in good repair and shall be leakproof and rodent-proof.

LPA observed fully charged fire extinguisher, smoke and carbon monoxide detectors throughout the facility. Storage areas for poisons are maintained in locked locations inaccessible to children. LPA advised Applicant to maintain first-aid supplies in an area readily accessible to staff but inaccessible to children. LPA observed water stains on the ceiling panels in the classroom. Applicant stated that there are no active water leaks and that the stained ceiling panels are scheduled to be replaced before the start of the new school year.

Lunch and snacks are prepared on-site in the elementary school kitchen and delivered to the children in the classroom. Parents also have the option of providing lunch and snacks for their children. The applicant was reminded that full-day programs must ensure each child has a lunch and that children must have access to drinking water at all times. Applicant stated that drinking water is readily available indoors and outdoors through water fountain from a filtered source, Sink faucets accessible to children dispense cold running water only.

LPA observed the kitchen area to be clean and free of litter and rubbish. The kitchen was observed to be off-limits to children and equipped with a refrigerator and food warming equipment. The applicant was advised that appropriate measures must be taken to keep the kitchen free of rodents and other vermin.

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Janette Cruz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: PGUSD STATE PRESCHOOL
FACILITY NUMBER: 274418512
VISIT DATE: 06/12/2026
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 outdoor areas designated for the preschool children were observed to be free of hazards, including holes, broken glass, dry grasses, and other debris that could pose a fire or safety risk. Shade is provided by trees and building overhangs. Areas surrounding and beneath high climbing structures are cushioned with poured rubber and tan bark to absorb falls. LPA observed playground climbing equipment indicating it is age appropriate for children ages 2-12 years old and is securely anchored to the ground. The playground is enclosed by the elementary school fencing which is at least four feet high to ensure children remain safely within the outdoor activity area. LPA observed that the preschool playground is located within an open outdoor space on the school campus. Applicant stated that cones and ropes will be used to clearly designate the preschool outdoor activity area and ensure children remain within the approved outdoor space. LPA observed no bodies of water. The applicant stated that there are no weapons are stored on the premises. The facility does not provide transportation services to children.

Drinking water from a non-contaminating fixture or container shall be readily available both indoors and in the outdoor activity area. LPA advised per Health and Safety Code 1597.16(a)(1) Lead Testing and PIN-21-21-CCP Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010 to test their drinking water for lead contamination between January 1, 2020 and January 1, 2023, and then every 5 years after the date of the first test.

Per Written Directive 100700(c)(1) Written Directives for Lead Testing (1) For a license issued on or after July 1, 2022, initial testing results shall be received and posted within 180 days of licensure.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A 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) or (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.

LPA discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep, as an additional resource. LPA also informed Applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Janette Cruz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: PGUSD STATE PRESCHOOL
FACILITY NUMBER: 274418512
VISIT DATE: 06/12/2026
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
LPA reviewed with the Applicant LIC 311A, Records to Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
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-care-licensing/subscribe and select the Child Care option to receive email communication.

The following corrections are needed before a licensure will be considered.
1. Approval of waiver to allow shared use of preschool outdoor activity yard with Forest Grove Elementary school-age children.
2. Verification that cones and ropes are available and will be used to clearly designate the preschool outdoor activity area to ensure children remain within the approved outdoor space.
3. Updated fire clearance to reflect classroom number and age range of the preschool children.
4. Final review of application documents.

An exit interview was conducted with the above items discussed. This report and appeal rights were provided to Abbie Arbrun, Applicant Representative. Final license determination will be made upon review by the Licensing Program Manager.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Janette Cruz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5