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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710435
Report Date: 05/29/2024
Date Signed: 05/30/2024 09:22:55 AM

Document Has Been Signed on 05/30/2024 09:22 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:MONTAGUE DISTRICT/STATE PRESCHOOLFACILITY NUMBER:
430710435
ADMINISTRATOR/
DIRECTOR:		GINA PEREZFACILITY TYPE:
850
ADDRESS:750 LAURIE AVENUETELEPHONE:
(408) 423-1931
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 14DATE:
05/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:15 PM
MET WITH:Zaithed Arias/SITE DIRECTORTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst(LPA) Anna Morales conducted a Case Management for an Unusual Incident that was reported to CCL(Community Care Licensing) on 5/22/24. LPA was greeted by Site Director Zaithed Arias. LPA observed 14 children engaging in activities with three staff supervising.

LPA conducted interviews with Staff(S1) and Site Director, toured the outdoor areas of the preschool and reviewed supporting documentation. Both stated that an incident occurred on 5/22/24, approximately at 10:51am while the children were playing outside and S1 exited(side gate)from the playground to greet a parent waiting at the entrance(Preschool) gate, and a child(C1) exited the playground. Staff stated that another child alerted Staff (S2, who was also supervising the children). S2 brought C1 back inside to playground.

No deficiencies were cited at today's visit.

NOTICE OF SITE VISIT WAS ISSUED AND DIRECTOR WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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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