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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430702544
Report Date: 12/19/2024
Date Signed: 12/19/2024 02:42:31 PM

Document Has Been Signed on 12/19/2024 02:42 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:WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAMFACILITY NUMBER:
430702544
ADMINISTRATOR/
DIRECTOR:		BOBBI URBANOFACILITY TYPE:
840
ADDRESS:1425 LINCOLN AVETELEPHONE:
(408) 287-6999
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 200TOTAL ENROLLED CHILDREN: 200CENSUS: 0DATE:
12/19/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Bobbi Urbano, DirectorTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Jennifer “Jen” Beehler and Darnella Barnes, met with Director, Bobbi Urbano, for an unannounced Required- 1 Year Inspection. LPAs were granted access to the facility by the School Principal. Staff arrived 10 minutes later and provided access to the classroom. LPAs toured both indoors and outdoors during the inspection. Upon arrival, there were 0 children and 4 staff (3 teachers / 1 Director) present, which is compliant with the facility license capacity and ratio requirements. LPA observed required postings were missing at the entrance. LPAs discussed with the Director and she stated they were electronically provided to parent's at all times. Parents mostly pick up children at the back of the school which is no where near the classroom. Director stated approximately 10% of parents pick up kids in the classroom. LPAs stated postings should be available at all times in the classroom. Director and staff printed and posted all required postings during the investigation. Hours of operation for the facility are Monday – Friday, 7:00AM-9:00AM and 2:50PM-6PM. The facility has an active waiver for electronic sign in/out.

Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. All staff present has a criminal record clearance.

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 missing sign out signatures from parents 4 out of 10 records that were reviewed.

Continued on Page 2
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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 7
Document Has Been Signed on 12/19/2024 02:42 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 12/19/2024 at 01:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAM
FACILITY NUMBER: 430702544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, 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: 01/10/2025
Plan of Correction
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Director to install a CO 2 Detector.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 in 1 out of 3 staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Mandated Reporter Training to be completed by all staff every two years. Proof of compliance shall be shared with LPA.
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
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/19/2024 02:42 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 12/19/2024 at 01:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAM
FACILITY NUMBER: 430702544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status as specified in Section 101220, and the following health information: (C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and record review, the licensee did not comply with the section cited above in 1 out of 5 children's files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Type B
Section Cited
CCR
101529.1(b)
Sign In and Sign Out
(b) Center staff shall sign in a school-age child who arrives at the center on his/her own.

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 in 4 out of 10 children's files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Director will work with new system to insure signatures are not missed daily. Director will provide proof of new signature pages for 10 students.
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
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2024 02:42 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 12/19/2024 at 01:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAM
FACILITY NUMBER: 430702544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101223(b)(1)
Personal Rights
(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]).

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 in 5 out of 12 children's files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Director to provide proof that all personal rights disclosure has been signed by parents.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Segura
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


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: WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAM
FACILITY NUMBER: 430702544
VISIT DATE: 12/19/2024
NARRATIVE
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Director states there is a policy that will fine parents for missing the sign out process. Director stated they were starting a new electronic system in January that would provide better oversight for when parents miss signatures.

The last fire/disaster drill was conducted on 05/10/2023, which is not compliant with the six month requirement for facilities. LPAs observed a fully charged 3A40BC fire extinguisher last serviced 01/01/2024, which is compliant with state marshal regulations. LPA observed a fully functioning smoke detector system. A CO2 detector was not observed during today's inspection.

Director states that she does currently have children in care who require Incidental Medical Services. Medication is properly stored out of reach of children, in a locked box, with the proper documentation. 1/5 medications reviewed were missing a completed LIC627. This facility provides Incidental Medical Services – IMS. LPAs reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. 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 are available at: https://www.ada.gov/resources/child-care-centers/.

Indoor areas of the facility were inspected by the LPAs today and observed to be clean, orderly, and safe for the day care children. LPAs observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via water fountains and children bring their own reusable bottles from home. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom, not utilized by the children. The Director has a working telephone in the facility. Cleaning and maintenance for the facility is conducted by the teachers daily after children in care leave. The Director states that there are no weapons or firearms on the premises.

Lead testing was discussed. Director stated the facility had provided a copy of their lead testing results, which all passed. LPA collected a copy of this report during inspection and will add it to the Regional Office file.

Continued on Page 3
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAM
FACILITY NUMBER: 430702544
VISIT DATE: 12/19/2024
NARRATIVE
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The outdoor area of the facility was inspected and observed to be fenced in. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (rubber padding) to absorb falls. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by building overhang and trees.

Food is provided by the facility and is stored, prepared, and served in a safe and healthful manner to the children. Facility provides (afternoon snack) to children. Menu is in writing and posted at least one week in advance, accessible to authorized representatives. The kitchen and storage area is clean and free of litter and rubbish. Equipment necessary for the storage, preparation and service of food is well maintained, clean, and sanitized after each use.

12 children’s files (school-age) were reviewed during today’s inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Signed Admission Agreement, and Immunization Records. LPAs observed 4/12 children missing signed personal rights.

3 staff files (1 director/ 3 teachers) were reviewed for the following records: Transcripts/Verification of Experience, Health Screening Report (LIC503), Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, Tuberculosis (TB) Clearance, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). There is at least one staff member present with current CPR/First-Aid that expires 01/24/2025. The Director's Mandated Reporter Training expired in 2023. LPA reminded the Director that the Mandated Reporter Training must be renewed by all staff every 2 years. 2/3 staff files were missing flu vaccination.

The Director understands that the site director 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. LPAs reminded 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.

Continued on Page 4
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: WILLOW GLEN COMMUNITY EXT.DAY ENRICHMENT PROGRAM
FACILITY NUMBER: 430702544
VISIT DATE: 12/19/2024
NARRATIVE
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During today's inspection the following documents were collected:

1. Updated Roster
2. Copy of facility snack menu
3. Copy of lead testing report and results

Exit interview conducted and report was reviewed with the Director, Bobbie Urbano.

As a result of today’s inspection, 5 Type B deficiencies were cited. More details provided on the attached LIC809Ds.

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 may 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 CARE tools, please send email inquiries 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.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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