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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400414
Report Date: 02/04/2026
Date Signed: 02/04/2026 05:33:02 PM

Document Has Been Signed on 02/04/2026 05:33 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 ACADEMYFACILITY NUMBER:
434400414
ADMINISTRATOR/
DIRECTOR:		BOUTHELLIER, RANDOLPHFACILITY TYPE:
850
ADDRESS:1590 MINNESOTA AVENUETELEPHONE:
(408) 266-8056
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 25TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
02/04/2026
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:08 PM
MET WITH:Randolph Bouthellier - LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Licensee, Randolph Bouthellier, for an unannounced Required- 3 Year Inspection. LPA was granted access to the facility by the Licensee and toured both indoors and outdoors during the inspection. Upon arrival, there were six (6) children (preschool-age) and 3 staff (1 - teacher/ 1 - assistant/ 1 - Director) present, which is compliant with the facility license capacity and ratio requirements. LPA observed all required postings near the entrance to the facility. Hours of operation for the facility are Monday – Friday, 06:30 AM-06:00PM. There are no active waivers.

Licensee, Randolph Bouthellier 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 had criminal record clearance and were associated to the roster on Guardian.

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 incomplete. The last fire/disaster drill was conducted on 12/22/2025, which is compliant with the six month requirement for facilities. LPA observed a fully charged 3A40BC fire extinguisher last serviced 08/15/2025, which is compliant with state fire marshal regulations. LPA observed a fully functioning smoke detector system, but a carbon monoxide detector was not present. Licensee states that he does not currently have any children in care who require Incidental Medical Services.

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NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2026
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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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)
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Document Has Been Signed on 02/04/2026 05:33 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 02/04/2026 at 02:06 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 ACADEMY
FACILITY NUMBER: 434400414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

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 in 1 out of 1 Carbon Monoxide Detector was not present which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2026
Plan of Correction
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Facility to install a Carbon Monoxide Detector in accordance to written directives. Facility to provide proof to LPA by POC due date.
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 record review and Director Interview, the licensee did not comply with the section cited above as a lead testing report was not available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Facility to complete water testing for lead contamination on all pipes that provide drinking water or water used for food preparation. Facility to provide LPA with a copy of the report prior to POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Deanna Villagrana
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2026 05:33 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 02/04/2026 at 02:06 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 ACADEMY
FACILITY NUMBER: 434400414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(a)
Buildings and Grounds
(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.

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 as two play structures had damage that was repaired with tape, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2026
Plan of Correction
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Facility to remove broken play equipment and provide LPA with proof prior to POC due date.
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 3 out of 3 staff did not have valid Mandated Reporter Training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2026
Plan of Correction
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All staff to complete Mandated Reporter Training and sign LIC9108 Statement Acknowledging the Requirement to Report Suspected Child Abuse by POC due date. Director to provide a written plan to ensure training is conducted every two years.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Deanna Villagrana
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2026 05:33 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 02/04/2026 at 02:06 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 ACADEMY
FACILITY NUMBER: 434400414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 in 3 out of 3 staff files did not have proof of influenza vaccination/declination and 2 out of 3 files did not have proo fof immunity to pertussis and measles, which poses a potential risk to the health, safety or personal rights of persons in care.
POC Due Date: 02/04/2026
Plan of Correction
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Facility to collect and maintain immunization records to ensure all staff are in compliance. Facility to provide a written plan to LPA on how staff files will be collected and maintained, prior to employment and during employment to ensure compliance, prior to POC due date.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

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 2 out of 5 children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2026
Plan of Correction
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Licensee to collect Physician's report from Children #04 and #05. Facility to provide proof along with a written plan on how records will be collected during the enrollment period to ensure the facility remains in compliance, by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Deanna Villagrana
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 02/04/2026 05:33 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 02/04/2026 at 02:06 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 ACADEMY
FACILITY NUMBER: 434400414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220.1(a)
Immunizations
(a) Prior to admission to a child care center, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, commencing with Section 6000.

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 5 children did not have proof of immunization to Measles which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2026
Plan of Correction
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Facility to collect updated immunization records to ensure all children in care have up to date immunization records. Facility to provide proof to the Department along with a written plan on how to maintain updated immunization records in the future to ensure facility remains in compliance, by POC due date.
Type B
Section Cited
CCR
101229.1(b)
Sign In and Sign Out
(b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.

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 6 children were missing sign in/out signatures for February. LPA observed past records to be incomplete with missing signatures from authorized representatives, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2026
Plan of Correction
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Facility to create and implement a plan to ensure parents are signing children in and out with full legal signatures. Facility to provide LPA with the written plan and proof that facility is in compliance by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Deanna Villagrana
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


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 ACADEMY
FACILITY NUMBER: 434400414
VISIT DATE: 02/04/2026
NARRATIVE
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This facility provides Incidental Medical Services – IMS. LPA 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 LPA today and observed to be clean, orderly, and safe for the day care children. LPA 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. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom, not utilized by the children, which an isolated child can use if necessary. The Licensee states a working landline is designated for the facility. Cleaning and maintenance for the facility is conducted by staff members every day. The Licensee states that there are no weapons or firearms on the premises.

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. Two (2) play structures had plastic tears that were repaired with tape, not in accordance with manufacturer's standards. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by canopy and building overhang.

Food is provided by the facility and is stored, prepared, and served in a safe and healthful manner to the children. Facility offers full day program and provides breakfast, lunch and afternoon snack to children. Menu was not posted during today's visit. 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. Drinking water is readily available for children in the facility via purified water from a third party vendor and children use their water bottles from home, labeled with their names.

Continued on Page 3
NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC809 (FAS) - (06/04)
Page: 9 of 12
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 ACADEMY
FACILITY NUMBER: 434400414
VISIT DATE: 02/04/2026
NARRATIVE
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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). CCC DID NOT COMPLETE TESTING PRIOR TO THEIR DEADLINE. LPA referred Licensee, Randolph Bouthellier, to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

Five (5) children’s files (preschool-age) were reviewed during today’s inspection for the following records: Physician’s Report (LIC701), Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Signed Admission Agreement, and Immunization Records (PM286).

Two (2) staff files (1 Director/ 1 - Teacher) were reviewed for the following records: Transcripts/Verification of Experience, Health Screening Report (LIC503), Employee Rights (LIC9052), 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. LPA observed files to have missing documentation relating to immunization records. There is at least one staff member present with current CPR/First-Aid that expires 09/2026. Staff present did not have valid Mandated Reporter Certificates. LPA reminded Licensee that the Mandated Reporter Training must be renewed by all staff every 2 years.

The Licensee 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. LPA reminded Licensee 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. LPA reviewed facility files with Licensee and provided the updated versions of the following documents:
  • LIC 700 ID and Emergency Information
  • LIC 701 Physician's Report
  • LIC 702 Health History

Continued on Page 4
NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC809 (FAS) - (06/04)
Page: 10 of 12
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 ACADEMY
FACILITY NUMBER: 434400414
VISIT DATE: 02/04/2026
NARRATIVE
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  • LIC 613A Personal Rights
  • LIC 501 Personnel Record
  • LIC 610 Emergency Disaster Plan
  • LIC 200A - Application
  • LIC 9108 Statement Acknowledging the Requirement to Report Suspected Child Abuse


LPA observed the last fire clearance on file was 03/13/1998 and the name on the fire clearance is Crayon Center. The LIC 610 does not have current staff listed in the emergency plans. LPA did observe the facility had a hard wired fire detection system for the whole facility. The LIC200A has corrections and the hours of operation are different from current operational hours. LIC999 Sketch has previous facility name of Crayon Center. LPA encouraged Licensee to update documents annually or as needed to ensure facility information is up to date and the Department is updated as changes occur at the facility.

LPA had a discussion with the licensee regarding the Resource and Referral agency of Santa Clara County which can be contacted by going to www.childcarescc.org, phone: (669) 212-5437, Email: childcarescc@sccoe.org.

Licensee 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 athttps://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.



Due to today's inspection, eight (8) Type B Deficiencies are cited along with two (2) Technical Violations. More details provided on the attached documents. Exit interview was conducted with Licensee, Randolph Bouthellier. Report was reviewed and provided to Randolph Bouthellier along with appeal rights.

Continued on Page 5
NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC809 (FAS) - (06/04)
Page: 11 of 12
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 ACADEMY
FACILITY NUMBER: 434400414
VISIT DATE: 02/04/2026
NARRATIVE
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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.
NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC809 (FAS) - (06/04)
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