434413145-9-1-2022-07-CC-KMEO-CHUNVV-20220901104835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413145
Report Date: 09/01/2022
Date Signed: 09/01/2022 10:48:41 AM

Document Has Been Signed on 09/01/2022 10:48 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	BLACKFORD PRESCHOOL		FACILITY NUMBER:	434413145
ADMINISTRATOR:	IGNACIO, MYLENE		FACILITY TYPE:	850
ADDRESS:	1970 WILLOW STREET		TELEPHONE:	(408) 341-7281
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY: 30	TOTAL ENROLLED CHILDREN: 22	CENSUS: 21	DATE:	09/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Nazy Ardalan		TIME 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, September 1st, 2022 at 8:10am Licensing Program Analyst (LPA) Kassandra Medrano met with Nazy Ardalan, Facility Representative, for an unannounced required 1 year annual inspection. LPA toured the indoor and outdoor areas of the Facility during today's inspection. LPA observed the required posted materials,including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), menus, and Activity Schedule. Days and hours of operation are Monday through Friday, 8:15am-11:15pm. The preschool program follows Campbell Unified School district schedule. The preschool age program is licensed for care in Rooms: 38, and 39 on Blackford school campus, but they are only currently using room 38 for care. This program operates on public school site. The following was observed today: Present in the facility were 21 preschool aged children, with 4 staff. The facility has a waiver on file. Nazy stated that when the program is in session, they have exclusive use of the playground. LPA reviewed ten children's and 4 staff files during today's inspection. Each child's file reviewed contains the required documents, including the Information and Emergency Information form (LIC 700) and immunization records. All staff files reviewed contain the required documents, including transcripts/verification of experience/immunization records, and Health Screening Report. All staff have current certificates of completion of the Mandated Reporter Training for Child Care Workers on file. Last fire/disaster drill was completed on 8/30/2022. The staff files that were reviewed have current CPR and First Aid certifications on file. Facility Representative understands 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 (field trips). LPA observed that the teacher/child ratio was in compliance during today's inspection. Facility representative understands the conditions, limitations, and capacity specifications of the Facility license. Facility representative understand that children shall be visually supervised at all times. Any child(ren) who exhibit symptoms of illness including, but not limited to, fever or vomiting, are not accepted in care. Any child(ren) who become ill during the day, shall be isolated in an area within the classroom. LPA observed that the Facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. The Facility has adequate ventilation, including central air conditioning/heating. Facility Representative understands that the Facility must be kept free of flies and other insects & rodents.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: BLACKFORD PRESCHOOL	FACILITY NUMBER: 434413145
	VISIT DATE: 09/01/2022

NARRATIVE

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LPA observed that all furniture and equipment is in good condition and safe for the children. Drinking water is readily available for the children in the Facility and in the outdoor playground area via filtered water and personal water bottles.Staff and children's bathrooms are clean, sanitary, and operable. Nazy states that there are no weapons or firearms on the premises. The Facility has functioning carbon monoxide detectors in the Facility. The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. The facility only provides snacks to the children, as the program is only a half day program.The Facility has trash cans with tight fitting lids for solid waste. Cleaning supplies are inaccessible to the children and stored in high cabinets inaccessible to children. Nazy, states that there are no poisons in the Facility. LPA observed a complete First Aid kit in the Facility, including a touch less thermometer. Director understands that smoking is not allowed on the Facility premises. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – This facility provides IMS. A review of storage of medications, equipment and supplies, and reviewed children, personnel and administrative records. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. Shade is provided by trees and building overhangs in the playground.LPA did not observe any bodies of water. Nazy, 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. The program is operated by the Campbell 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.
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/process.

Exit interview conducted and report was reviewed with the Facility Representative, Nazy. No deficiencies cited during today's inspection. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

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