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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415769
Report Date: 10/17/2022
Date Signed: 10/18/2022 08:08:25 AM

Document Has Been Signed on 10/18/2022 08:08 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:CHILDREN'S COURTYARD, THEFACILITY NUMBER:
434415769
ADMINISTRATOR:ANNABELLE CALASANZFACILITY TYPE:
830
ADDRESS:610 E DUNNE AVENUETELEPHONE:
(408) 778-1977
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 16DATE:
10/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Annabelle CalasanzTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management- Other inspection. LPA met with Director Annabelle Calasanz and explained the reason for the inspection. The purpose of this inspection is lead testing completed with an exceedance. The facility had a result of 17.3 ppb.

During today's inspection, LPA inspected the faucets that had an exceedance, which is the water fountain located to the right of the staff break room. LPA observed that there was no sign or anything to ensure it is not being used. Water fountain was functioning during today's inspection. Director stated that they took off the plastic when maintenance came out to fix the water fountain. Director placed a plastic over the water fountain during today's inspection. LPA did not observe any children drinking from the water fountain during today's inspection. LPA discussed with Director that the facility needs to ensure that it is not being used due to elevated lead levels.

LPA obtained a copy of the LIC 9275, LIC 9276, and facility sketch which indicates the location of all water outlets during today's inspection.

Facility had a work order placed to fix the water fountain on 10/07/2022 through EMCOR Facilities Services. Director stated that they had someone from EMCOR come out on 10/13/2022 and is waiting for a part. He will be returning on 10/20/2022 to replace the part in the water fountain.

-----------------continuation of 809 dated 10/17/2022 page 2----------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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Document Has Been Signed on 10/18/2022 08:08 AM - It Cannot Be Edited


Created By: Samantha Yip On 10/17/2022 at 01:06 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: CHILDREN'S COURTYARD, THE
FACILITY NUMBER: 434415769

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives. A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement is not met as evident by:
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Director placed a plastic over the water fountain during today's inspection to keep it out of use.
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The water fountain located to the right of the staff break room had a result of 17.3 ppb, which poses an immediate health and safety risk to children in care.
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Facility placed a work order to have water fountain fixed on 10/07/2022. Director confirmed that it will be completed by 10/20/2022.

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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: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


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: CHILDREN'S COURTYARD, THE
FACILITY NUMBER: 434415769
VISIT DATE: 10/17/2022
NARRATIVE
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-------------------continuation of 809 dated 10/17/2022 page 1--------------------

LPA Samantha Yip informed Director Annabelle Calasanz that this report dated 10/17/2022 documents one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Director, Annabelle Calasanz, to provide a copy of this licensing report dated 10/17/2022 that documents any Type A citation(s) 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.

Facility will submit the following:
  • lead test results

As a result of this inspection, a Type A citation was issued. Exit interview was conducted and report was reviewed with Director Annabelle Calasanz. A notice of site visit has been issued and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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