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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417124
Report Date: 03/15/2024
Date Signed: 03/15/2024 04:38:44 PM

Document Has Been Signed on 03/15/2024 04:38 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ICARE CHILDREN'S HOUSE MONTESSORI PRESCHOOLFACILITY NUMBER:
434417124
ADMINISTRATOR:YAN GONGFACILITY TYPE:
850
ADDRESS:2555 MOORPARK AVENUETELEPHONE:
(408) 398-2033
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 83TOTAL ENROLLED CHILDREN: 6CENSUS: 5DATE:
03/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Yan GongTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Oscar Huang met with licensee, Yan Gong for an unannounced case management visit. LPA explained the nature of today’s inspection to licensee.

LPA learned that the facility did not provide the food stated on the menu, did not have a fully qualified teacher at all time observing and supervising children, nor to physically separate from physical areas and activities with preschoolers and a toddler.

Three type "B" deficiencies were cited. Deficiencies, Plan of Corrections (POCs), and Appeal Rights were discussed with licensee Yan Gong. and the report, appeal Rights were provided to her. Exit interview conducted with licensee, Yan Gong.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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Document Has Been Signed on 03/15/2024 04:38 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 03/15/2024 at 02:22 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: ICARE CHILDREN'S HOUSE MONTESSORI PRESCHOOL
FACILITY NUMBER: 434417124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
101227(a)(6)

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Food Services: Menus shall be in writing and shall be posted at least one week in advance in an area accessible for review by the child's authorized representative.
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Licensee agreed to submit a written Plan of Correction detailing what steps will be implemented to ensure that the facility is in compliance with food service requirements prior to POC due date.
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This requirement is not met as evidenced by: The facility did not provide the food stated on the menu. This poses a potential risk to the health, safety, and personal rights to children in care.
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Type B
03/29/2024
Section Cited
CCR101216.3(a)

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Teacher-Child Ratio: (a)There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance.
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Licensee agreed to submit a written Plan of Correction detailing what steps will be implemented to ensure that the facility is in compliance with Teacher-Child Ratio requirements prior to POC due date.
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This requirement is not met as evidenced by: The facility did not have a fully qualified teacher at all time observing and supervising children. This poses a potential risk to the health, safety, and personal rights to children in care.
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/15/2024 04:38 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 03/15/2024 at 02:42 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: ICARE CHILDREN'S HOUSE MONTESSORI PRESCHOOL
FACILITY NUMBER: 434417124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
101216.4(a)(2)

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Preschool Program with Toddler Component: (a)(2) The toddler program shall be conducted in areas physically separate from those used by older or younger children.
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Licensee agreed to submit a written Plan of Correction detailing what steps will be implemented to ensure that the facility is in compliance with preschool program with toddler component requirements prior to POC due date.
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This requirement is not met as evidenced by: The facility did not physically separate from physical areas and activities with preschool and toddler groups. This poses a potential risk to the health, safety, and personal rights to children in care.
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024


LIC809 (FAS) - (06/04)
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