434417121-9-12-2023-07-CC-FRAA-CVLL8U-20230912083231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417121
Report Date: 09/11/2023
Date Signed: 09/12/2023 08:32:39 AM

Document Has Been Signed on 09/12/2023 08:32 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:	ALLSTARS STEM ACADEMY OF EVERGREEN		FACILITY NUMBER:	434417121
ADMINISTRATOR:	MADAN BELLAM		FACILITY TYPE:	840
ADDRESS:	2650 ABORN ROAD		TELEPHONE:	(408) 406-3728
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 60	CENSUS: 0	DATE:	09/11/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Madan Bellam		TIME COMPLETED:	01:15 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 Analysts (LPAs), Farida Raja and Marilou Monico conducted an announced pre-licensing inspection. LPAs met with Director/Applicant Representative, Madan Bellam. The applicant is applying for a school age license for 60 children, ages 5-17 years. The center will operate Monday through Friday from 12:30 PM to 6:30 PM and 8:00 AM to 6:30 PM during school breaks in room 1 and 2 of Grace Church. ABC Evergreen Preschool is located at the same address but operates in different rooms. A fire clearance approval from the San Jose Fire Department was granted for 60 children on 08/01/2023. LPAs toured and measured the indoor and outdoor areas of the facility during today's inspection. Indoor Activity Space: Room 1: 48.083 X 35.000 = 1,682.905 Room 2: 19.250 X 13.250 = 255.062 minus 16.420 (encumbered space) = 238.642 sq ft *TOTAL INDOOR SPACE = 1,921.547 sq. ft. divided by 35 = 54 children.* The facility has 1 sink (15) and 2 toilets (30) available for the children. The sink used by children only has cold running water. The staff bathroom is next to the children's bathroom. The isolation of sick children will be in the right side section of Room 1 next to the bathrooms and isolation equipment will be provided. Sick children will use the staff bathroom if needed and will be accompanied by a staff member. Staff and children's bathrooms are sanitary and operable. LPAs advised applicant to purchase a trash can with a tight fitting lid. LPAs observed appropriate lighting in the classroom. The facility has central heating and air conditioning. First aid supplies are located in an upper locked cabinet in the kitchen. Cleaning products are stored in a high shelf in the kitchen inaccessible to children. Director stated that there are no weapons or firearms on the premises. LPAs observed two fire extinguishers, functioning smoke and carbon monoxide detectors in the room. Continued on Page 2

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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 09/12/2023 08:32 AM - It Cannot Be Edited

Created By: Farida Raja On 09/11/2023 at 12:13 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: ALLSTARS STEM ACADEMY OF EVERGREEN	FACILITY NUMBER: 434417121
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1596.80

Child day care facilities, licenses: No person, firm, partnership, association, or corporation shall operate, establish, manage, conduct, or maintain a child day care facility in this state without a current valid license, therefor as provided in this act. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the Applicant did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPAs learned that facility has already started operations.
	POC Due Date: 09/11/2023
	Plan of Correction
1 2 3 4	Applicant has already submitted an application for a child care center license which is pending licensure. Notice of Operation in Violation of Law was given to Director during today's visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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: ALLSTARS STEM ACADEMY OF EVERGREEN	FACILITY NUMBER: 434417121
	VISIT DATE: 09/11/2023

NARRATIVE

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Medications will be locked in a lock box in locked kitchen cabinet.

LPAs observed that all furniture and equipment is in good condition and safe for the children. The facility will serve afternoon snack to the children. There is an off-limits kitchen for food preparation. The kitchen is clean and equipped with hot and cold running water, refrigerator, stove, oven, microwaves and storage space for food. Disposable utensils and plates will be utilized by the facility. There are 25 tables, 106 chairs and 40 hooks for the children. There is adequate equipment, supplies, and materials for the school age children. Drinking water will be readily available for the children both indoors and outdoors via individual water bottles and refilled using a water pitcher. Transportation will be provided by the facility.

OUTDOOR MEASUREMENTS:
Soccer Field: (80.417 X 93.500) + (79.667 X 93.500)
7,518.989 + 7,448.864 = 14,967.853 minus 638.064 (encumbered space) = 14,329.789 sq ft
TOTAL OUTDOOR SPACE = 14,329.789 sq. ft. divided by 75 = 191 children

The school age program will share the outdoor play area (soccer field) with a preschool (ABC Evergreen Preschool) on the same premises. Director will submit a waiver for the shared playground space including outdoor schedules. LPAs observed that the playground is surrounded by appropriate fencing and the outdoor surfaces are safe. Shade is provided by trees, tent and a gazebo. The entire outdoor area is covered with grass. There were no bodies of water observed. Director was reminded that initial lead testing results shall be received within 180 days from licensure. Following the initial testing, facility must conduct water testing every 5 years after the date of the first test.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. Applicant will wait until facility opens to determine IMS needs. 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, available at: http://www.ada.gov/childqanda.htm

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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: ALLSTARS STEM ACADEMY OF EVERGREEN	FACILITY NUMBER: 434417121
	VISIT DATE: 09/11/2023

NARRATIVE

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Director were reminded that all adults 18 and over, responsible for the administration or direct supervision of staff, persons who provide 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 Facility Representatives the LIC 311A, Records to Be Maintained at The Facility, for child’s records, personnel records, administrative records, and documents to be posted. Assembly Bill (AB 633) was discussed with Facility Representatives. Facility Representatives were 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&R) throughout California.

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.

LPAs advised director that a license for 30 Preschool children will be submitted to management for approval upon receiving the following items:

1) Updated facility sketch including isolation area, outdoor play area with dimensions and kitchen as an off-limit area.

2) Installation of portable sink along with a written statement stating how the clean water is connected to the faucet and how the dirty water will be disposed.
3) Submit waiver for Outdoor Space (soccer field) along with outdoor schedules.
4) Pending receipt of approved fire clearance for 30 children.
5) Purchase of additional trash can with tight fitting lid.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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: ALLSTARS STEM ACADEMY OF EVERGREEN	FACILITY NUMBER: 434417121
	VISIT DATE: 09/11/2023

NARRATIVE

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Based on interviews and email submitted to LPA Raja, LPAs learned that the facility has started operation while pending licensure. Type A deficiency was cited today on the attached LIC 809D page. Appeal rights were printed and given to Applicant Representative.

Exit interview conducted and report was reviewed with Director/Applicant Representative, Madan Bellam. Director submitted an updated Application during today's inspection changing the capacity to 30 school-age children, updating ages of children served and hours of operation.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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