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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417300
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:57:29 AM

Document Has Been Signed on 01/26/2023 11:57 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:BELLGRAD EVERGREEN STEM ACADEMYFACILITY NUMBER:
434417300
ADMINISTRATOR:ARULKUMAR SUNDARRAMANFACILITY TYPE:
840
ADDRESS:CLASSROOM 31, 3010 FOWLER ROADTELEPHONE:
(408) 568-3674
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 35TOTAL ENROLLED CHILDREN: 35CENSUS: 0DATE:
01/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Arul SundarramanTIME COMPLETED:
12:15 PM
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On 01/26/2023 at 10:00 AM, Licensing Program Analyst (LPA), Susy Cervantes, conducted an announced pre-licensing visit to the Facility today. LPA met with Arulkumar Sundarraman, managing partner, and explained the nature of today's visit to them. LPA toured the Facility both inside and outside during today's visit. The school age program will operate Monday through Friday 2:00 PM to 6:15 PM and Wednesdays from 12:30 PM to 6:15 PM. A fire clearance for 35 children was received from the San Jose Fire Department prior to today's visit.

Facility representative 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, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

The school age program is exempt from indoor and outdoor square footage requirements, sink/toilet ratios, isolation space, and fencing requirements since it is located at a functioning public schools site. A capacity letter (35 children in Room 31) from the Evergreen Elementary School was received prior to today's visit.



LPA observed no fireplaces or wall heaters at the facility. Air conditioning is provided in the room. The room has appropriate lighting. The center will be administering medication and the medication lock box is located in the classroom. First aid supplies are stored in the classroom, are adequate and are inaccessible to children. Carbon monoxide detectors are operable. There is a 3A40BC fire extinguishers that was serviced on 10/18/22. Cleaning supplies will be stored in a locked cabinet under the sink in the classroom. The center will be providing snacks for the children and snacks will be prepared in the classroom. Disposable dishes and cups will be utilized for the children. LPA observed a solid waste container with tight-fitting lid. There are 32 cubbies, 4 tables, 28 individual desks, and 33 chairs. Drinking water is available indoor and outdoor by drinking fountains. The program will utilize the campus playground which has an age appropriate climbing structure with sufficient resilient materials.

Continues on report dated 01/26/2023 _______________________________________ pg 1/2
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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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: BELLGRAD EVERGREEN STEM ACADEMY
FACILITY NUMBER: 434417300
VISIT DATE: 01/26/2023
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Continuation of report dated 01/26/2023 _______________________________________ pg 2/2

The school age program will use the playground after public schools hours. Shade is provided by two large trees and canopies. There is adequate equipment and supplies for children outdoors. LPA did not observe any bodies of water during today's visit. The children’s bathrooms are located allow for individual privacy. Staff have designated bathrooms separate from the children's. There is one working telephone numbers for the program which is (408) 568-3674.

LPA reviewed with managing partner, Arulkumar Sundarraman 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 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.

Exit interview conducted and report was reviewed with the managing partner, Arul Sundarram. LPA advised applicant that licensure for 35 children is approved pending the following:

-Management approval

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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