434417135-2-13-2025-07-CC-MMOO-DDV25P-20250213160553

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417135
Report Date: 02/13/2025
Date Signed: 02/13/2025 04:08:00 PM

Document Has Been Signed on 02/13/2025 04:08 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	TESSELLATIONS CHILDREN'S CENTER		FACILITY NUMBER:	434417135
ADMINISTRATOR/ DIRECTOR:	STEPHANIE HOLSON		FACILITY TYPE:	850
ADDRESS:	1170 YORKSHIRE DRIVE		TELEPHONE:	6502604409
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY: 36	TOTAL ENROLLED CHILDREN: 33	CENSUS: 30	DATE:	02/13/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:02 AM
MET WITH:	Stephanie Holson & Matt Linden		TIME VISIT/ INSPECTION COMPLETED:	02:30 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) Marilou Monico met with Site Director, Stephanie Holson, and Co-Director, Matt Linden, for an unannounced Annual Random inspection and to remeasure Rooms 30 and 31. The purpose of today's inspection was explained with Matt and Stephanie. LPA observed all the required postings. The center's operating hours are Monday through Thursday from 8:15 AM to 6:00 PM and Fridays from 8:15 AM to 5:00 PM. The facility is licensed to serve children ages 3 years old to 5 years old in Rooms 30 and 31. LPA toured the indoor and outdoor areas. LPA observed that the teacher-child ratio was in compliance. Fire drill was conducted on January 22, 2025. The facility has current children's roster. Cleaning products, disinfectants, sharp objects were stored inaccessible to children. Furniture and equipment were observed to be age appropriate and in good condition. The facility is clean. The bathrooms for children and staff are clean, sanitary, and operable. The center provides morning and afternoon snacks to children. Parents have the option to purchase lunch from "My Green Lunch" or bring lunch to their children. Drinking water is available for the children via drinking fountain and individual water bottles. LPA observed trash cans with tight fitting covers for the disposable of solid waste. The facility has the required size fire extinguisher and working smoke and carbon monoxide detectors. Stephanie stated that there are no weapons or firearms on the premises. LPA reviewed 10 random children's files. Children records reviewed include Admission Agreement, Identification and Emergency Information, Consent for Emergency Medical Treatment, Parent Right's Receipt, Physician's Report with tuberculosis test, Child's Preadmission Health History, Immunization Record, and Personal Rights. *Continuation on next pages:*

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: TESSELLATIONS CHILDREN'S CENTER	FACILITY NUMBER: 434417135
	VISIT DATE: 02/13/2025

NARRATIVE

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LPA reviewed eight staff files. Staff records reviewed include Employee Rights, Statement Acknowledging Requirement to Report Child Abuse, Health Screening Report with TB Clearance, Immunizations (Measles, Pertussis, and Influenza) and required training. Staff #4 is missing immunizations in measles, pertussis, and flu. Staff #8 is missing pertussis and flu. Staff #3 and #7 are missing health screening (LIC 503). LPA reminded Matt that the Mandated Reporter Training shall be renewed by all staff every two years. At least one staff member present during the inspection has current Pediatric CPR/First Aid certifications.

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 Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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/resources/child-care-centers/.

Co-Director, Matt Linden, 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.

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).

LPA verified that the lead testing was completed in accordance to the Written Directives
outlined in PIN 21-21.1-CCP.
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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: TESSELLATIONS CHILDREN'S CENTER	FACILITY NUMBER: 434417135
	VISIT DATE: 02/13/2025

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Co-Director, Matt Linden, 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&R's) throughout California.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

During today's inspection, LPA measured the following indoor space available for the children:
Rooms 30 & 31 = 1,826.37 minus 313.49 (encumbered space) = 1,512.88
Total Preschool Indoor Space = 1,512.88 divided by 35 sq. ft. = 43 children

As a result of this inspection, Type B deficiencies were cited on the following page.

Exit interview conducted and report was reviewed with Co-Director, Matt Linden.

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

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/13/2025 04:08 PM - It Cannot Be Edited

Created By: Marilou Monico On 02/13/2025 at 03:16 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: TESSELLATIONS CHILDREN'S CENTER	FACILITY NUMBER: 434417135
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Staff #4 is missing immunizations in measles, pertussis and flu, Staff #8 is missing immunizations in pertussis and flu which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2025
	Plan of Correction
1 2 3 4	Co-director, Matt, stated that he will submit proof of immunizations for the two staff by 03/13/25.

Type B

Section Cited

CCR

101216(g)(1)

Personnel Requirements

(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Staff #3 and #7 are missing health screening report which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2025
	Plan of Correction
1 2 3 4	Matt stated that a completed health screening report for the two staff will be submitted to Licensing by 03/13/25.

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:

Marilou Monico

LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

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