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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407563
Report Date: 05/01/2024
Date Signed: 08/27/2024 08:49:32 AM

Document Has Been Signed on 08/27/2024 08:49 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ABC LEARNING MONTESSORIFACILITY NUMBER:
434407563
ADMINISTRATOR/
DIRECTOR:		DIANA MANIXFACILITY TYPE:
850
ADDRESS:1115 KIMBERLY DRIVETELEPHONE:
(408) 448-4578
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 49TOTAL ENROLLED CHILDREN: 39CENSUS: 31DATE:
05/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Diana ManixTIME VISIT/
INSPECTION COMPLETED:
06:25 PM
NARRATIVE
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* This report has been amended to correct the age of the children observed in the classroom on the LIC 809D page.

On 05/01/2024 at 3:10pm, Licensing Program Analysts (LPAs), Farida Raja and Samantha Yip conducted an unannounced Case Management Inspection. LPAs met with Licensee Diana Manix and explained the reason for the inspection. On 12/08/2024, during an inspection, Staff (S1) was observed present in the facility. S1 has criminal background clearance but no transfer of criminal record clearance from ABC Learning Montessori #434414335 to ABC Montessori #434407563 has been requested.

During today's facility inspection, LPAs reviewed staff and children's files. Through file review, LPAs observed child, C6 is missing the physician's report. Through staff file review, LPAs observed staff, S1 is missing the Health Screening Report. LPAs obtained a copy of the water least test report conducted on 06/08/02023 including Childcare Center Sampling Checklist Form (LIC 9276), External Water Sampler Self Certification Form (LIC 9275) and facility sketch including all water outlets.

During facility walk through, LPAs observed a child using the bathroom without staff supervision. Staff position did not enable them to view the child using the bathroom. Children's medication was reviewed. LPAs observed child C7 does not have the epinephrine auto injector in original container.

Five Type B deficiencies were cited today on the attached LIC 809-D pages. Appeal rights were printed and provided to Director. Exit interview conducted and report was reviewed with Director, Diana Manix.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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 4
Document Has Been Signed on 05/01/2024 08:21 PM - It Cannot Be Edited


Created By: Samantha Yip On 05/01/2024 at 03:43 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: ABC LEARNING MONTESSORI
FACILITY NUMBER: 434407563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2023
Section Cited
CCR
101170(e)(2)

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Criminal Record Clearance (e) All individuals subject to a criminal record...shall prior to working, residing or volunteering...(2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or
This requirement is not met as evidenced:
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Director submitted a written plan of correction on 12/09/2023.
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Based on observation, interview and record review, the licensee did not comply with the section cited above for staff, S1, which poses a potential health, safety or personal rights risk to persons in care. LPA observed staff, S1 working with children without having fingerprint clearance transferred to this facility.
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Type B
05/15/2024
Section Cited
CCR101216(g)(1)

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101216 Personnel Requirements (g) (1) Except as specified in (3) below, good physical health shall be verified by a health screening... performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.
This requirement is not met as evidenced by:
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Director will provide a plan of correction to LPA by POC date of 05/15/2024.
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Based on staff file review, LPAs observed staff, S1 does have a health screening report (LIC 503) on file.
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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:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document is an Amendment of Original Document on 08/22/2024 01:44 PM


Created By: Farida Raja On 05/01/2024 at 04:58 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ABC LEARNING MONTESSORI
FACILITY NUMBER: 434407563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
101220(a)

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101220 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 requirements is not met evidenced by:
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Director to provide POC to LPA by due date of 05/15/2024
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Based on children's file review LPAs observed child C6 is missing the physician's report.
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Request Denied
Type B
05/15/2024
Section Cited
CCR101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a)(1) No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation.
This requirement is not met as evidenced by:
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Director to provide POC to LPA by due date of 05/15/2024
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During facility walk through, LPAs observed a child using the bathroom in the 3-4 year old room without staff supervision.
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/01/2024 08:21 PM - It Cannot Be Edited


Created By: Samantha Yip On 05/01/2024 at 05:37 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: ABC LEARNING MONTESSORI
FACILITY NUMBER: 434407563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
101226(e)(B)

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101226 Health-Related Services (e) In centers where the licensee chooses to handle medications: (B) Each container shall have an unaltered label.
This requirement is not met as evidenced by:
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Director will submit a plan of correction to LPA by POC due date of 05/15/2024.
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During medication review, LPAs observed child, C7 does not have an epinephrine auto injector in original container.
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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:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


LIC809 (FAS) - (06/04)
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