<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408804
Report Date: 10/12/2022
Date Signed: 10/12/2022 11:14:49 AM


Document Has Been Signed on 10/12/2022 11:14 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:GOLDEN HARVEST MONTESSORI SCHOOLFACILITY NUMBER:
434408804
ADMINISTRATOR:KASSIM ALIFACILITY TYPE:
850
ADDRESS:1905 NORTH MILPITAS BOULEVARDTELEPHONE:
(408) 719-1686
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:80CENSUS: 44DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:12 AM
MET WITH:Kassim AliTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On Wednesday, October 12, 2022 at 8:12 am, Licensing Program Analyst (LPA) Manel Estoesta conducted an unannounced required one (1) Year Visit. LPA met with the Director Kassim Ali and the Licensee Kimberly Ali and explained the nature of the site visit. Present on this visit were 11 staff and 44 preschool children. Facility operates from Monday to Friday 7:30 am to 6:30 pm.

LPA toured the facility to conduct a Health and Safety Inspection with the Director and Licensee. The facility has 5 classrooms utilized for the preschool program. The rooms Junior Adventure and Racketeer are located next to facility's Main Entrance and adjacent to the fenced front yard facing the street. The rooms Cosmos and Shooting Star and Nebula are located next to the play yard. Facility’s License, Parents’ Rights Poster, Personal Rights, Activity Schedules and Waiver were observed to be posted. Facility was observed to follow teacher to children ratio requirement during LPAs' inspection. Children were engaged in various activities under the visual supervision of the teachers.
The classrooms, restrooms, pantry, storage room, and office area were inspected. The facility does not possess nor store any weapons on the premises.
Disinfectants, cleaning solutions, and other items that are dangerous to children were stored inaccessible to children. Cabinets, drawers, and rooms used for storage were locked. Furniture and equipment such as mats, cots, tables, and chairs were age appropriate and were in good condition, free of sharp, loose, or pointed parts. Restrooms for children's use were observed to be in safe, sanitary, and functioning condition. Floors were clean and free from tripping hazard.
Outdoor activity space is fenced and was inspected. The play equipment was maintained in a safe condition and free of hazards. There were no bodies of water observed. Areas around and under high climbing equipment and slides were cushioned with material that absorbs falls. There were shaded rest areas for children. Drinking water are arranged to be readily available to children during indoor and outdoor activities. LPA obtained a copy of the facility's LIC 610.

SEE 809 C.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GOLDEN HARVEST MONTESSORI SCHOOL
FACILITY NUMBER: 434408804
VISIT DATE: 10/12/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continuation...

LPA observed Smoke and Carbon Monoxide Detectors, fire pull stations, fire extinguishers and sprinkler system. Faciliity conducted a Fire and Earthquake Disaster Drills on July 2022. LPA reviewed the facility's Fire Department Inspection Permit that will expire on 12/31/2022.

Facility does not provide transportation for children, but Director understands that children cannot be left alone, unattended in park vehicles.

Children's lunches were brought from home. Snack (provided on AM and PM) Menus were posted.
Food storage area were clean, free of litter, rubbish, and rodents/vermin. Trash cans for solid waste had tight-fitting covers on and were in good repair.
Facility files were reviewed. Children sign in and out procedures and logs were reviewed. Facility is currently using an electronic sign in and out system called "ProCare application". LPA reviewed the children's "Roll Call" sheet in each room. LPA obtained a copy of today's children's sign in sheet.

A sampling of Children's files was taken for review. The records reviewed include Admission Agreement, Identification and Emergency Information, Medical Assessment, and Immunization. Facility currently has a waiver to have 12 School Age Children and no current School Age enrolled at this time and Children's Roster.
A sampling of Staff's files was taken for review. Facility is currently using an electronic sign in and out system called "ProCare application". LPA obtained a copy of today’s staff sign in sheet and LIC 500.

Staff present have current certification in Pediatric CPR and First Aid, and AB 1207 Child Care Providers training online at https://mandatedreporterca.com/ requires 2 year requirement. LPA reviewed Staff Immunization records of Measles and Pertussis immunization, Influenza vaccination and TB clearance. LPA reminded Facility Representative that only the Influenza vaccination can be decline with a written declination.

LPA discussed the PIN 21-21-CCP RELEASE OF THE WRITTEN DIRECTIVES FOR LEAD TESTING OF
WATER IN LICENSED CHILD CARE CENTERS PER AB 2370. The Licensee stated that she will request for a waiver for the Lead Testing.

SEE 809.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC809 (FAS) - (06/04)
Page: 2 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GOLDEN HARVEST MONTESSORI SCHOOL
FACILITY NUMBER: 434408804
VISIT DATE: 10/12/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continuation....

Director stated that facility does handle medications and the facility does not have children in care who requires Incidental Medical Services - IMS Epinephrine and Inhaled 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 (TTY) and link to publication: Commonly Asked Questions about Child Care centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

Facility Representative 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.

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.

There are no deficiencies cited on this visit.

A notice of site visit was given and must remain posted for 30 days.



Exit interview conducted and report was reviewed with the Licensee and the Director, Kimberly Ali.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3