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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416369
Report Date: 11/18/2022
Date Signed: 11/18/2022 12:43:04 PM

Document Has Been Signed on 11/18/2022 12:43 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KIDSPARKFACILITY NUMBER:
434416369
ADMINISTRATOR:DEBBIE MILNERFACILITY TYPE:
840
ADDRESS:820 S WINCHESTER BLVD #120TELEPHONE:
(408) 206-3404
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 0DATE:
11/18/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Debbie Milner, Lisa Alvarado, & Melissa PetersTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Marilou Monico met with Applicant Representative, Debbie Milner, Site Director, Lisa Alvarado, and Teacher, Melissa Peters, for the purpose of conducting a pre-licensing inspection.

The School Age Program will operate Monday through Thursday (8:00 AM to 10:00 PM), Friday (8:00 AM to midnight), Saturday (10:00 AM to midnight), and Sunday (1:00 PM to 6:00 PM) serving school age children ages 5-10 years old. LPA observed that the facility has no outdoor areas available for the children.

LPA toured and measured the indoor areas of the facility during today's inspection.

Indoor Activity Space:
BLUE CREW = 22.667 x 17.583 = 398.553
TOTAL INDOOR SPACE = 398.553 sq. ft. divided by 60 sq. ft. = 6 children

The School Age Program has two bathrooms, one (1) toilet and one (1) sink for each bathroom, and provide individual privacy. The sinks used by children only have cold running water. There is a staff bathroom with one (1 toilet) and one (1) sink located next to the school age bathrooms. The sick children will be using the Staff Bathroom if needed. Sick children will be isolated in the Reception Area by the entrance and isolation equipment will be provided. Staff and children's bathrooms are clean, sanitary, and operable.

LPA observed containers with tight-fitting lids for the disposal of solid waste. First aid supplies are stored in the upper cabinet located in the Creation Station Room inaccessible to children. Cleaning supplies are stored in the locked closet near the staff bathroom. LPA observed smoke/carbon monoxide detectors and appropriate lighting in each classroom. The facility has central heating and air conditioning. Medications will be stored in plastic container located in the upper cabinet in the Creation Station Room.
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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIDSPARK
FACILITY NUMBER: 434416369
VISIT DATE: 11/18/2022
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Debbie understands that the facility must be kept free of flies, other insects & rodents. There are 2 tables and 12 chairs available for the children. LPA observed that all furniture and equipment indoors are in good condition and safe for the children. Debbie states that additional furniture, equipment, and supplies will be moved to this site once licensed. Drinking water will be readily available for the children indoors via drinking fountains. Transportation will not be provided by the facility.

The facility will serve morning and afternoon snacks, evening snacks if the center is open. Debbie states that lunch and dinner will be catered to the center from a third party vendors. There is a food preparation area in the Creation Station Room. The food preparation area is equipped hot and cold running water, refrigerator, freezer, dishwasher, and storage space for food. Disposable utensils and plates will be utilized by the facility.
This facility plans to provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A Plan of Operation that includes IMS must be submitted to the Department. 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.

Applicant Representative was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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.

LPA reviewed with Applicant Representative the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIDSPARK
FACILITY NUMBER: 434416369
VISIT DATE: 11/18/2022
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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.

Fire Clearance for 50 school age children was granted on November 2, 2022.

Exit interview conducted and report was reviewed with Debbie Milner, Applicant Representative. LPA advised Debbie that waiver requests are being reviewed by Licensing Management for the final stage of approval. Final license approval to be completed by Licensing Management.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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