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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400480
Report Date: 08/31/2022
Date Signed: 08/31/2022 11:30:53 AM

Document Has Been Signed on 08/31/2022 11:30 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
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) 423-3816
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 44TOTAL ENROLLED CHILDREN: 15CENSUS: 13DATE:
08/31/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Judie StevensTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA), Cortney Nelson, met with staff member, Ruth Hernandez, who states that Site Supervisor, Judie Stevens, is out on an errand and will return soon. Upon arrival, LPA explained purpose of visit to Ruth, follow-up on incident that occurred on 8/25/2022 and interview staff. LPA toured inside and outside of the facility and conducted COVID risk assessment. While touring outside playground, Site Supervisor, Judie, arrived to the facility.

Visit today is in response to an incident that occurred that was called into the San Jose Regional Office (SJRO) by Site Supervisor, Judie, to report that on 8/25/2022 around 11:35AM a child was forgotten in the classroom after washing hands when returning from the playground. In the report, it was noted that the child was alone for approximately 2-3 minutes before returning to the classroom where all other children and staff were present. Unusual Incident Report (LIC624) was received by the SJRO on 8/26/2022 and Site Supervisor states that she additionally notified the parent of the child involved in the incident of its occurrence.

LPA conducted interviews with staff involved in the incident as well as the Site Supervisor. Site Supervisor states that the typical routine is for children to be split into two groups for hand washing as the facility has inclusion program and some children may require more individualized attention. Also, there is limited sink space in classroom 21, so the group utilizes 2 additional sinks located in classroom 34. Since the incident, follow-up training has been conducted with the staff involved as well as changes in the procedure for hand washing and ratio maintenance.

During todays visit, LPA discussed with Site Supervisor strategies for safe ratio management of the children and ways to ensure similar situation does not occur again in the future. Judie states that moving forward, the same 3 children will always accompany a designated staff member to room 34 for hand washing. White boards have been posted to clearly identify the number of children and staff present during the day and Site Supervisor states that walkie talkies have been ordered for utilization too.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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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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: 08/31/2022
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LPA obtained copy of children's roster and training document (conducted 8/26/2022) signed by teachers involved in the incident during todays inspection. LPA additionally requested personnel roster (LIC500), however Site Supervisor states that she has not been able to create one yet. LPA wrote down names of all staff involved in supervision at the preschool from each program (Paraeducators and Student Adapted Instruction-SAI) instead.

During todays visit, LPA additionally became aware of new Site Supervisor at the facility who states that she started at the beginning of August 2022. The department has not been made aware of the new Site Supervisor and LPA requested that she submit all required documents for review.

Exit interview conducted and report was reviewed with Site Supervisor, Judie Stevens.

As a result of todays inspection, deficiencies have been cited, see 809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

LPA informed Site Supervisor, Judie Stevens, that this report dated 8/31/2022, documents one Type A citation, which shall be posted for 30 consecutive days as there was immediate risk to the health, safety, or personal rights of children in care.

Also, LPA informed the Site Supervisor to provide a copy of this licensing report dated 8/31/2022 that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
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Document Has Been Signed on 08/31/2022 11:30 AM - It Cannot Be Edited


Created By: Cortney Nelson On 08/31/2022 at 10:38 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: POMEROY DISTRICT PRESCHOOL
FACILITY NUMBER: 434400480

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2022
Section Cited
CCR
101229(a)(1)

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101229- Responsibility for Providing Care and Supervision (a) The Licensee shall provide care and supervision as necessary to meet the childrens needs. (1) No child(ren) shall be left without the supervision of a teacher at any time... supervision shall include visual observation.

This requirement was not met as evidenced by:
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The Site Supervisor conducted retraining (8/26/2022) on supervision and accountability at the facility with staff involved in the incident. Additional methods have been created to ensure proper ratios and new routine for hand washing.
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The Site Supervisor and staff did not ensure child in care had visual supervision at all times when the child was left in classroom 34 unattended which is an immediate risk to the health, safety, and personal rights of children in care.
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No additional POC follow-up needed, corrections made by the facility following the incident.
Type B
09/15/2022
Section Cited
CCR101212(b)

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101212- Reporting Requirements (b)The name of the child care director...shall be reported to the Department within 10 days of a change of child care director or designee(s).

This requirement was not met as evidenced by:
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Site Supervisor will submit all required documents for review by the Department by 9/15/2022. LPA provided list of required documents to be submitted to the Site Supervisor.
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The current Site Supervisor at the facility states that she started at the beginning of August 2022, however the Department was not notified of the change, which is a potential risk to the health, safety, and personal rights 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.
SUPERVISOR'S NAME:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022


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