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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400480
Report Date: 11/05/2021
Date Signed: 11/05/2021 12:03:23 PM

Document Has Been Signed on 11/05/2021 12:03 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:POMEROY DISTRICT PRESCHOOLFACILITY NUMBER:
434400480
ADMINISTRATOR:AUDREY RANDAZZOFACILITY TYPE:
850
ADDRESS:1250 POMEROY AVE. RM #21 & 34TELEPHONE:
(408) 423-3817
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 44TOTAL ENROLLED CHILDREN: 44CENSUS: 12DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Richard CoriaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Anna Morales conducted an Annual Required Inspection. LPA was greeted by Site Director Richard Coria. The Facility is located on the campus of Pomeroy Elementary School in Rooms 21 and 34. LPA was informed that only Classroom 34 is being occupied at this time. Operating hours are 7:00am-6:00pm. Last disaster drill was conducted on 10/21/21.

The program is operated by the Santa Clara Unified School District and all criminal background checks for staff are handled by the Department of Education and thus do not come under the jurisdiction of Community Care Licensing Division.

LPA observed 12 students, the Director and one teacher present. Facility was observed to be in compliance with teacher to child ratio requirement during visit.

Outdoor activity space is enclosed by fencing and is observed to be free of hazards. LPA observed play equipment were in good condition. LPA observed resilient materials under the climbing structures. Drinking water was readily available to children indoor and outdoor. Activities schedule and Snack Menu were posted. Facility provides breakfast, and an afternoon snack. LPA observed that food storage areas were clean and free of litter.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: POMEROY DISTRICT PRESCHOOL
FACILITY NUMBER: 434400480
VISIT DATE: 11/05/2021
NARRATIVE
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Observed a fully charged B 402 fire extinguisher. in the front area of the classroom. The Carbon monoxide is interconnected with the Emergency Fire Alarm. LPA was informed that the parents use a electronic sign/sign out. LPA obtained a current Children''s Roster. Observed age appropriate furnishings.

This facility is providing Incidental Medical Services – IMS Plan. There is a Nurse on grounds and a Nurses Station for children who require medical attention. None of the children currently enrolled are using medication. LPA reviewed storage of medication and equipment/supplies, and reviewed children's personnel and administrative records. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ)toll-free ADA Information Line at (800)514-0301(voice)/(800)514-0383 (TYY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/chidlqanda.htm

LPA reviewed a random selection of children files. Children records reviewed include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, Medical Assessment, Immunization.

LPA reviewed Staff's records reviewed include Criminal Record and Child Abuse Index Clearance, Health Screening Report and TB test, Immunization (Measles, Pertussis, and Flu) record and required Training. LPA reminded Director that the online AB1207 Mandated Reported Training needs to be renewed every two years. There was at least one person with current certification in Pediatric CPR and First Aid present at the facility.

SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: POMEROY DISTRICT PRESCHOOL
FACILITY NUMBER: 434400480
VISIT DATE: 11/05/2021
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Director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.


LPA discussed the requirements of AB 633 with the Director and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Exit interview conducted and report was reviewed with the Director Richard Coria. No deficiencies cited at today's visit.


To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC809 (FAS) - (06/04)
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