434416695-3-21-2024-07-CC-FRAA-D3KMRF-20240321095016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416695
Report Date: 03/20/2024
Date Signed: 03/21/2024 09:51:12 AM

Document Has Been Signed on 03/21/2024 09:51 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:	LITTLE OAK NURSERY		FACILITY NUMBER:	434416695
ADMINISTRATOR:	JENNIFER POTMESIL		FACILITY TYPE:	830
ADDRESS:	1921 CLARINDA WAY		TELEPHONE:	(408) 369-1252
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY: 16	TOTAL ENROLLED CHILDREN: 19	CENSUS: 12	DATE:	03/20/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jennifer Potmesil		TIME COMPLETED:	01:00 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), Farida Raja, met with Director, Jennifer Potmesil, for an unannounced Annual inspection in the Infant Program. The facility is licensed to serve children from birth to 24 months in rooms 8 and 9. Facility has a preschool program (#434416693) at the same location. LPA observed the required posted materials in the office area and Emergency Disaster Plans (LIC 610) in classroom. Days and hours of operation are Monday through Friday, 8:00 am to 5:00 pm. LPA and Director toured the indoor and outdoor areas of the Infant Program during today's inspection and observed the following ratios: Room 8 (Butterflies): 6 children and 3 teachers Room 9 (Honeybees): 6 children and 3 teachers Facility was in compliance with teacher to children ratio requirement. Children were engaged in free play under supervision of teachers. Facility has central heating/cooling for comfort of children. Director states that there are no weapons or firearms on the premises. There is a working telephone at the facility (408-369-1252). Disinfectants, cleaning products, sharp items and medicines were stored inaccessible to the children in care. All cabinets and drawers used for storage were locked. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. LPA observed solid waste containers with tight-fitting lids in the rooms. LPA observed appropriate changing tables that have raised sides (3 inches in height), have vinyl changing pads that are at least 1 inch thick and are within arm's reach of a sink. LPA observed trash can with tight fitting cover for the disposal of diapers. Napping equipment (mats/cribs) are appropriate. LPA observed sleep sacks, blankets and toys inside the crib but no children were napping during the inspection. LPA advised Director that an exception needs to be requested for each child to use a sleep sack while napping and that toys and blankets need to be removed from the crib when placing an infant to sleep. Continued on Page 2

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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: LITTLE OAK NURSERY	FACILITY NUMBER: 434416695
	VISIT DATE: 03/20/2024

NARRATIVE

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There are two staff bathrooms at the facility in the office building. There is a separate bathroom for sick children located in Room 11. Sick children will be isolated in Director's office and isolation equipment will be provided. Staff and children's bathrooms are clean, sanitary, and operable.

First aid supplies are stored in each classroom inaccessible to children and in the office area. Cleaning supplies are stored in the high cabinets in each room out of reach of children. LPA observed fire extinguishers, working smoke and carbon monoxide detectors, and fire pull stations. The facility has a built-in smoke detector/ fire system. Log shows that the last Fire Drill was conducted on 03/19/2024 which is compliant with the six-month requirement for facilities.

Drinking water is readily available for children in each room and in the outdoor playground area via individual water bottles or sippie cups. Director stated that no water outlets are used for drinking or food preparation purposes. All infant food is prepared and provided by parents. Drinking water is refilled using a pitcher filled with filtered store bought water. Director stated that they have always had water delivered since the opening of the facility. LPA asked Director to submit a written attestation stating that they exclusively use a delivery service to provided filtered water and no outlets at the facility are used for drinking water and food preparation purposes including for washing dishes or fruit/vegetables. LPA asked Director to submit a facility sketch indicating all water outlets as well.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

All food is prepared and provided by parents and LPA observed labelled containers with each child's food placed in them inside the refrigerator. Food and beverages were stored safely to prevent contamination and spoilage and observed to be sanitary. LPA observed refrigerators, microwaves and bottle warmers in each room. Director stated that all staff are aware of food allergies or dietary restrictions, which are outlined in children's files.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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: LITTLE OAK NURSERY	FACILITY NUMBER: 434416695
	VISIT DATE: 03/20/2024

NARRATIVE

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LPA observed the playgrounds are surrounded by appropriate fencing and the outdoor surfaces are safe. Shade is provided by trees and canopies. LPA observed tanbank and artificial turf as resilient material under and around the climbing structures. No bodies of water were observed. Infants use the middle tanbark area next to the black top area and the deck area of the garden. Director stated that infants use the tan bark area when no preschool children are present.

Children sign in and out logs were reviewed. Children's roster was reviewed, and a copy was provided to the LPA. LPA reviewed five (5) children’s files during today's inspection. Each child's file reviewed contained the required forms. Needs & Services Plans were on file and updated at least once per quarter or more often if needed. Facility was in compliance with the Safe Sleep regulations/requirements, including the Infant Sleeping Plan (LIC 9227) and 15 minute nap checks.

LPA discussed the safe sleep regulations with Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Driector of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. LPA observed a recalled Fischer-Price rocker in Room 8 (Butterflies Room). LPA informed Director of PIN 19-16-CCP informing provider of a recall on inclined infant sleep devices and provided a copy during today's inspection

Three (3) staff files were reviewed. All teachers and staff maintain valid background clearances. All staff files reviewed contain the required transcripts including infant toddler units and verification of experience. At least one staff member on site has a current CPR and First Aid certification on file. Director 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). All staff have the required immunization's against pertussis, measles and influenza (or statement declining the immunization). LPA observed required Mandated Reporter Training on file for all staff.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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: LITTLE OAK NURSERY	FACILITY NUMBER: 434416695
	VISIT DATE: 03/20/2024

NARRATIVE

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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.

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. Facility has an approved IMS Plan on file with San Jose Regional Office. Medications are stored in each classroom out of reach of children. On review, LPA observed that non prescription medication for child C6 did not have written parent authorization. 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/.

Facility does not provide transportation to children, Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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

Two (2) Type B deficiencies and one technical violation were cited today on the attached LIC 809D pages. Appeal rights were printed and provided to Licensee. LPA reminded Licensee that failure to correct deficiencies by Plan of Correction Due Date may result in civil penalties. Exit interview was conducted with Director, Jennifer Potmesil.

NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/21/2024 09:51 AM - It Cannot Be Edited

Created By: Farida Raja On 03/20/2024 at 01:21 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: LITTLE OAK NURSERY	FACILITY NUMBER: 434416695
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101226(e)(4)(B)

Health-Related Services

(B) For each nonprescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited for child, C6, which poses a potential health, safety or personal rights risk to persons in care. LPA observed Children's Motrin for child C6 but did not have written consent from parents/authorized representatives to administer medication.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Director will obtain written consent from parent provide a plan of correction to LPA by 04/03/2024.

Type B

Section Cited

CCR

101239(r)

101239 Fixtures, Furniture, Equipment and Supplies (r) Fixtures, furniture, and equipment that have been banned or recalled by the United States Consumer Product Safety Commission shall not be used or on the facility’s premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited which poses a potential health, safety or personal rights risk to persons in care. LPA observed two inclined sleepers in Room 8 (Butterflies Room) which are not allowed on child care center premises. LPA referred Director to PIN 19-16-CCP, Subject: Consumer Product Safety Commission (CPSC) urges consumers not to use inclined infant sleep devices.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Director will provide a plan of correction to LPA by 04/03/2024.

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:

Gladys Kuizon

LICENSING EVALUATOR NAME:

Farida Raja

LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC809 (FAS) - (06/04)

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