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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417071
Report Date: 08/10/2023
Date Signed: 08/10/2023 03:58:49 PM

Document Has Been Signed on 08/10/2023 03:58 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:LUCCIOLA ACADEMYFACILITY NUMBER:
434417071
ADMINISTRATOR:NOPPAKET PONGCHANAFACILITY TYPE:
850
ADDRESS:1711 HAMILTON AVENUETELEPHONE:
(661) 703-7818
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 106TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/10/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Noppaket PongchanaTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Mel Matos & Jessica Bongardt, met with Noppaket Pongchana, Applicant Representative/Director, for the purpose of conducting an announced prelicensing inspection The Applicant has applied for an infant #434417072 and preschool (Rooms 2-5) with a toddler option (Room 5 & 6) #434417071 - license on the same site.

Initial prelicensing inspection was completed on August 3, 2023 and Noppaket Pongchana, Applicant Representative/Director, was advised that the following would be required prior to approval of an infant license for 77 preschool & 24 infant/toddler children.

1) Follow up inspection has been completed to verify that the Facility is fully set up with adequate equipment, supplies, and toys for the children.
2) The area near the electrical power panel in the preschool playground is made off limits to children.
3) Waiver for playground space and shared place has been submitted and approved.
4) Updated fire clearance approval for 101 children (77 preschool & 24 toddler option) has been received from the San Jose Fire Department.

Note: Measurements of the Facility were completed by LPAs Matos and Bongardt on August 3, 2023.

The food preparation area is functional and has hot and cold running water, sink, dishwasher, two refrigerators, microwave, stove/oven, and storage space for food. Noppaket states that the Facility will provide all meals, including snacks and lunch to the children. Cleaning and sanitation of dishes and utensils will be done via dishwasher. Disposable utensils and plates will be utilized by the Facility. LPAs did not observe solid waste containers with a tight-fitting lid in Rooms 1-6. Cleaning supplies will be stored on high shelves and locked cabinets in Rooms 1-6 inaccessible to children.

There are 22 chairs, 5 tables, 16 cubbies, and 24 hooks for the infant/toddler children. There are 49 chairs, 15 tables, 8 cubbies, and 43 hooks for the preschool children. There is inadequate equipment, supplies and toys for the children based on the capacity requested on the Application. Noppaket understands that walkers, and items of similar nature are not permitted. LPAs observed appropriate changing tables that have raised sides (3 inches in height) and are within an arm's reach of a sink in Rooms 5 & 6.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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 2
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: LUCCIOLA ACADEMY
FACILITY NUMBER: 434417071
VISIT DATE: 08/10/2023
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Drinking water will be provided indoors/outdoors via water jugs/sippie cups/reusable water bottles. There is a working telephone at the Facility. The phone number is 661-703-7818. The area near the electrical power panel in the preschool playground has been made off limits to children.

LPAs discussed the safe sleep regulations with Applicant representative and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep, as an additional resource. LPAs also informed Applicant representative 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.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. 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.

Noppaket 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, 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.

LPAs 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.

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 platforms. 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.

Exit interview conducted and report was reviewed with Applicant Representative/Director, Noppaket Pongchana. LPAs advised Noppaket that a license for 101 children (24 toddler option & 77 preschool) will be approved upon completion of the following:

1) A waiver request for the shared playground space/lack of sufficient space with the infant children has been submitted & approved.
2) Updated fire clearance approval for 101 children has been received from the San Jose Fire Department.
3) Sufficient napping mats, tables, chairs, and hooks/cubbies for the capacity requested (101).
4) Trash cans with tight fitting lids have been purchased for Rooms 3-7.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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