434417300-1-8-2025-07-CC-FRAA-DCQMTR-20250108085354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417300
Report Date: 01/07/2025
Date Signed: 01/08/2025 08:54:06 AM

Document Has Been Signed on 01/08/2025 08:54 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:	BELLGRAD EVERGREEN STEM ACADEMY		FACILITY NUMBER:	434417300
ADMINISTRATOR/ DIRECTOR:	RONIT ROSE		FACILITY TYPE:	840
ADDRESS:	3010 FOWLER ROAD, CLASSROOM 31		TELEPHONE:	(408) 568-3674
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY: 70	TOTAL ENROLLED CHILDREN: 70	CENSUS: 50	DATE:	01/07/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:10 PM
MET WITH:	Ronit Rose		TIME VISIT/ INSPECTION COMPLETED:	06:05 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	On 01/07/2025 at 2:10pm, Licensing Program Analysts (LPAs), Farida Raja and Syhshyan Yu, met with Director, Ronit Rose and Owner, Arulkumar Sundarram for an unannounced annual inspection in the school age program. The facility is licensed to serve 70 children ages 4.9 to 12 years in Rooms 30 and 31. Facility is located on the Evergreen Elementary School campus. LPAs observed the required posted materials in each classroom. Days and hours of operation are Monday through Friday 2:00 PM to 6:00 PM and Thursdays from 12:30 PM to 6:00 PM. Children began arriving at 2:35pm after dismissal from school. LPAs toured the indoor and outdoor areas and observed the following ratios: Room 30- 27 children: 3 staff Room 31- 23 children : 2 staff Facility was in compliance with teacher to children ratio requirement. Facility has central heating/cooling for comfort of children. Owner states that there are no weapons or firearms on the premises. There is a working telephone at the facility. Disinfectants and cleaning products were stored in child locked cabinet inaccessible to the children in care. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. LPAs observed solid waste containers with swing top covers in both rooms. LPAs reminded Owner that all containers used for storage of solid waste shall have a tight-fitting cover. Restrooms allow for individual privacy and were observed to be safe, sanitary, and in working condition. Staff have designated bathrooms separate from the children's. LPAs observed fire extinguisher, built-in smoke detector/ fire system. Log shows that the last Fire Drill was conducted on 01/06/2025 which is compliant with the six-month requirement for facilities. Drinking water is readily available for children in each room and in the outdoor playground area via individual water bottles. Water lead testing was completed for the facility on 03/15/2024 and no Action Level Exceedances were reported. Continued on Page 2

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: BELLGRAD EVERGREEN STEM ACADEMY	FACILITY NUMBER: 434417300
	VISIT DATE: 01/07/2025

NARRATIVE

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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. LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. LPA provided Director with the Water Lead Report from the California State Water Resources Control Board during today's inspection. Owner will submit a copy of the LIC 9275, LIC 9276 and facility sketch indicating water outlets tested to LPA by 01/21/2025.

Facility provides PM snack to the children in care. Menu was observed to be posted on refrigerator in Room 31. LPAs observed that the refrigerator used to store food was not clean. LPAs reminded Director that food storage and preparation areas need to be clean and free of litter and rubbish.

The school age program use the elementary school playground after public schools hours. The playground was surrounded by appropriate fencing and the outdoor surfaces are safe for children. LPAs observed that the play equipment is age appropriate, in good condition and free of hazards. There is artificial grass as resilient material in the outdoor playground area. Areas around and under high climbing equipment and slides were cushioned with resilient material. There are no bodies of water observed. Shade is provided by trees.

Children sign in and out procedures and logs were reviewed. LPAs reviewed 8 children’s files during today's inspection. Each child's file reviewed contained the required forms including the LIC 9224 for Type A violations cited on 12/10/2024.

Three (3) staff files were reviewed. All teachers and staff maintain valid background clearances. All staff files reviewed contain the required transcripts/verification of experience. At least one staff member on site has a current CPR and First Aid certification. Owner understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips). Upon file review, LPAs observed one staff (S1) is missing proof of immunization's for measles and the health screening report (LIC 503). LPAs observed required Mandated Reporter Training on file for all staff.

Continued on Page 3

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: BELLGRAD EVERGREEN STEM ACADEMY	FACILITY NUMBER: 434417300
	VISIT DATE: 01/07/2025

NARRATIVE

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Owner 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.

This facility provides Incidental Medical Services – IMS. Owner stated that they do not have any children that require medications including IMS at this time. For IMS information see PIN 22-02-CCP. Facility has an approved IMS Plan on file with San Jose Regional Office. Owner stated that any medications at the facility will be stored in high cabinets out of reach of children. Isolation of sick child was discussed, and Owner stated that sick children will be isolated at the back of the classroom and isolation equipment will be provided. Child is always under visual supervision while in care of the facility. 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 are available at: https://www.ada.gov/resources/child-care-centers/.

Facility does not provide transportation to children. Owner 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&Rs) throughout California.

Exit interview conducted and report was reviewed with Owner, Arul Sundarram and Director, Ronit Rose.

Two Type B deficiencies and 3 technical violations were cited a result of today's inspection. Appeal rights provided.

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

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/08/2025 08:54 AM - It Cannot Be Edited

Created By: Farida Raja On 01/07/2025 at 05:30 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: BELLGRAD EVERGREEN STEM ACADEMY	FACILITY NUMBER: 434417300
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

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 interview, observation and record review, the licensee did not comply with the section cited above for one staff (S1) which poses a potential health, safety or personal rights risk to persons in care. Staff is missing proof of immunization for measles.
	POC Due Date: 01/21/2025
	Plan of Correction
1 2 3 4	Owner to obtain proof of immunization/immunity for staff, S1 and submit to LPA by plan of correction date of 01/21/2025.

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 interview, observation and record review, the licensee did not comply with the section cited above for one staff (S1) which poses a potential health, safety or personal rights risk to persons in care. Staff is missing the health screening report (LIC 503).
	POC Due Date: 01/21/2025
	Plan of Correction
1 2 3 4	Owner to obtain missing LIC 503 for one staff, S1 and submit proof to LPA by plan of correction date of 01/21/2025.

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: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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