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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417300
Report Date: 10/25/2024
Date Signed: 10/28/2024 08:57:09 AM

Document Has Been Signed on 10/28/2024 08:57 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:BELLGRAD EVERGREEN STEM ACADEMYFACILITY NUMBER:
434417300
ADMINISTRATOR/
DIRECTOR:		EMERALD PEOPLEFACILITY TYPE:
840
ADDRESS:3010 FOWLER ROAD, CLASSROOM 31TELEPHONE:
(408) 568-3674
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 70TOTAL ENROLLED CHILDREN: 61CENSUS: 42DATE:
10/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:54 PM
MET WITH:Swetha NadamuniTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 10/25/2024 at 3:55pm, Licensing Program Analyst (LPA), Farida Raja conduced an unannounced case management inspection. LPA met with Owner, Shwetha Nadamuni and informed her of the purpose of today's inspection.

LPA observed a total of 42 children and 4 staff within the two classrooms toured at the facility. Based on interview with Owner, Owner has not submitted a Director packet for the new director within the required 10 days.

One Type B deficiency was cited today on the attached LIC 809D pages. Appeal rights were printed and provided to Owner. Exit interview was conducted with Owner, Shwetha Nadamuni.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/28/2024 08:57 AM - It Cannot Be Edited


Created By: Farida Raja On 10/25/2024 at 04:18 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: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
101212(b)

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101212 Reporting Requirements
(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).This requirement is not met as evidenced by:
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LPA reviewed Director's packet during today's visit and it was not complete. Owner to submit a complete Director packet to LPA by plan of correction due date of 11/08/2024. Any future Director changes shall be reported to the Department within 10 days.
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Based on interview with Owner, Owner has not submitted a Director packet for the new director within the required 10 days. This poses a potential risk to the health, safety and personal rights of 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:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


LIC809 (FAS) - (06/04)
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