434413114-12-12-2024-07-CC-JBER-DBVRX4-20241212122407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413114
Report Date: 12/12/2024
Date Signed: 12/12/2024 12:24:22 PM

Document Has Been Signed on 12/12/2024 12:24 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	WILLOWS NURSERY SCHOOL, THE		FACILITY NUMBER:	434413114
ADMINISTRATOR/ DIRECTOR:	ARIAS CHAVEZ, LEYDI		FACILITY TYPE:	850
ADDRESS:	1149 MINNESOTA AVENUE		TELEPHONE:	(408) 352-5601
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY: 17	TOTAL ENROLLED CHILDREN: 17	CENSUS:	DATE:	12/12/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:35 AM
MET WITH:	Leydi Arias Chavez - Director		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

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	Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Director, Leydi Arias Chavez, for an unannounced Required- 1 Year Inspection. LPA was granted access to the facility by the Director and toured both indoors and outdoors during the inspection. Upon arrival, there were 10 children (preschool aged) and 2 staff (teacher and director) present, which is compliant with the facility license capacity and ratio requirements. LPA observed all required postings near the entrance to the facility. Hours of operation for the facility are Monday – Thursday, 09:00AM-03:30PM, Friday 9:00AM-1:00PM (September - May). The summer program is from 9:00AM-1:00PM (June-August) The facility has no active waivers. Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. All staff present have criminal record clearance and are associated with the facility on Guardian. LPA reviewed sign-in/out sheets, facility roster (LIC9040), and fire/disaster drill log during today’s inspection. Sign-in/out was observed to be completed with full legal signature and time of day. The last fire/disaster drill was conducted on 11/22/2024, which is compliant with the six month requirement for facilities. LPA observed a fully charged 3A40BC fire extinguisher last serviced 01/17/2024 which is compliant with state fire marshal regulations. LPA observed a fully functioning smoke detector system for the entire facility and a working carbon monoxide detector. Director states that she currently has two children in care who require Incidental Medical Services. LPA observed the medications are properly stored out of reach of children with the proper documentation. Continued on Page 2

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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 12/12/2024 12:24 PM - It Cannot Be Edited

Created By: Jennifer Beehler On 12/12/2024 at 11:10 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: WILLOWS NURSERY SCHOOL, THE	FACILITY NUMBER: 434413114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(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:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 4 staff files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2024
	Plan of Correction
1 2 3 4	Director to locate missing immunization records for staff person before staff returns to work at facility. Director to provide LPA with photographic evidence of immunization record.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jennifer Beehler

LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: WILLOWS NURSERY SCHOOL, THE	FACILITY NUMBER: 434413114
	VISIT DATE: 12/12/2024

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

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and
administrative records.
For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Indoor areas of the facility were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via bottled water that is placed in pitchers in addition to water bottles from home labeled with the children’s names. Children’s bathroom is clean, sanitary. One of the two toilets was not functioning during today's inspection. Director stated it started leaking water yesterday so they shut it off and called the plumber. The plumber is scheduled for Friday to repair. There is a separate staff bathroom, not utilized by the children, LPA observed it to be clean orderly and operable. Director stated there is a land line for a working telephone in the facility. Cleaning and maintenance for the facility is conducted by the teachers as needed throughout the week and a deep cleaning on Friday where everything is dusted and vacuumed. Most of the activities are conducted outside. The Director states that there are no weapons or firearms on the premises.

The outdoor area of the facility was inspected and observed to be fenced in. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (sand) to absorb falls. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by canopy, pergola and trees. The facility mostly operates outdoors. There are different sections for student engagement. A mud kitchen, art easels, a rock climbing wall, bikes and books. There is a separate structure called the art studio filled with art materials. There is a drama corner with a stage for student performances. During today's inspection, it was raining. Children were prepared in full body rain suits and loved playing in the rain.

Continued on Page 3

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: WILLOWS NURSERY SCHOOL, THE	FACILITY NUMBER: 434413114
	VISIT DATE: 12/12/2024

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

Food is brought from home. LPA observed parents dropping off lunch boxes in a communal area. All lunch boxes were unique and had child's names. The kitchen was observed to be clean and orderly, but no food preparation is completed for children in care. There is no food stored for children in care.

5 children’s files (preschoolers) were reviewed during today’s inspection for the following records: Physician’s Report (LIC701), Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Signed Admission Agreement, and Immunization Records (PM286). All files were observed to be complete. 4 staff files (1 director, 2 teachers and 1 aide) were reviewed for the following records: Transcripts/Verification of Experience, Health Screening Report (LIC503), Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, Tuberculosis (TB) Clearance, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza or statement declining influenza. There is at least one staff member present with current CPR/First-Aid that expires 09/2025. The Director has current Mandated Reporter Training that expires on 08/25/2025. Two staff people were missing immunization records. The Director stated staff person was a substitute teacher and does not teach here very often. LPA reminded the Director that the Mandated Reporter Training must be renewed by all staff every 2 years.

The Director understands that the site director shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. LPA reminded the Director that there shall be at least one person with valid CPR and First-Aid certifications on site at all times or present during off site activities, such as field trips.

During today's inspection, one Type B deficiency was cited. More information provided on the attached LIC809-D. Exit interview conducted with Director, Leydi Arias Chavez, report was reviewed and provided along with appeal rights. NOTICE OF SITE VISIT PROVIDED AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4