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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400414
Report Date: 03/04/2026
Date Signed: 03/04/2026 11:49:25 AM

Document Has Been Signed on 03/04/2026 11:49 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: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: 5DATE:
03/04/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Randy BouthellierTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 03/04/2026, Licensing Program Analyst (LPA) Jennifer "Jen" Beehler conducted an unannounced Case Management/ Plan of Correction Inspection. Upon arrival LPA was greeted by the Facility Representative and provided access to the facility. LPA stated the reason for the visit, toured the inside and outside of the facility and collected the census.

There were five (5) preschool age children, three (3) staff (1 - Teacher/ 1 - Aide/ 1 - Director) present which is compliant with the ratio and capacity requirements. There was an Applied Behavioral Therapist present observing one of the children in care.

LPA conducted a file review and children's files were complete. LPA observed the sign in/out log to be complete for February and March for all five children in care. LPA reviewed staff files and observed one staff file missing a physician's report, TB test and immunization records for MMR. All staff present had completed the Mandated Reporter training. Licensee's certificate expires 03/02/2028. LPA observed all staff present had valid CPR/First Aid certification. Licensee's training expires 09/2026.

LPA observed the broken play equipment had been removed from the playground. An updated menu dated March 2026 was posted on the bulletin board near parent's entrance. A working CO2 detector was mounted in the main day care area. Lead testing for water used for children's consumption had not been conducted by today's visit. Licensee provided LPA with a written declaration detailing the steps the facility would take to ensure children were safe until a third party had tested the water. This plan included using disposable products for service and using a water delivery service for the water that would clean the fruits and vegetables before consumption with. Licensee will provide LPA with a copy of the lead testing report by 04/04/2026 or will reach out to the LPA to advise if the report will not be available by that day.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2026
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 03/04/2026 11:49 AM - It Cannot Be Edited


Created By: Jennifer Beehler On 03/04/2026 at 11:20 AM
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: 03/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2026
Section Cited
HSC
1596.7995(a)(1)

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(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:
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Licensee to collect proof of Measles vaccination from staff and email proof to LPA prior to POC due date. Licensee to provide written plan how he will track and maintain staff records in accordance with written directives.
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Staff #1 did not have Measles vaccination present during inspection. This poses a potential risk to the health, safety and personal right of children in care.
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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.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2026


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: 03/04/2026
NARRATIVE
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LPA observed the Licensee had updated the LIC610 to reflect current staff. During today's visit, the following documents were collected:
  • Declaration Statement from Licensee - Regarding plan of correction steps until the water is tested for lead contamination.
  • Updated LIC200A with correct facility name and hours.
  • LIC308 - Updated showing correct staff person as designee in Licensee's absence.


Based on today's inspection, one (1) Type B deficiency and a Civil Penalty are cited. More details provided on the attached LIC809-D and LIC421FC. Exit interview conducted with Licensee. Report was review and provided to Licensee, Randolph Bouthellier along with appeal rights.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026
LIC809 (FAS) - (06/04)
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