434417300-3-5-2026-07-CC-FRAA-DRW2XC-20260305164656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417300
Report Date: 03/05/2026
Date Signed: 03/05/2026 04:47:04 PM

Document Has Been Signed on 03/05/2026 04:47 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:	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: 30	CENSUS: 23	DATE:	03/05/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:25 PM
MET WITH:	Ronit Rose		TIME VISIT/ INSPECTION COMPLETED:	04:55 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 03/05/2026, Licensing Program Analyst (LPA), Farida Raja, met with Director, Ronit Rose for an unannounced annual/random 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. LPA 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. LPA toured the indoor and outdoor areas and observed 23 children with 3 staff in the outdoor area. Facility was in compliance with teacher to children ratio requirement. Director stated they are only using Room 31 this academic year. Room 30 is not in use. Facility has central heating/cooling for comfort of children. Director 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 under the sink and are inaccessible to the children in care. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. LPA observed solid waste container with tight fitting cover in the classroom. 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. Director stated that the classroom is cleaned daily and vacuumed by staff at the end of each day. LPA observed a serviced fire extinguisher and built-in smoke detector/ fire system. Log shows that the last Fire Drill was conducted on 01/29/2026 which is compliant with the six-month requirement for facilities. Continued on Page 2

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: BELLGRAD EVERGREEN STEM ACADEMY	FACILITY NUMBER: 434417300
	VISIT DATE: 03/05/2026

NARRATIVE

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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. 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.

Facility provides PM snack to the children in care. Menu was observed to be posted on refrigerator in Room 31. Food storage and preparation areas were observed to be sanitary. Food was observed to be stored in covered containers.

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. LPA 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. LPA reviewed five children’s files during today's inspection and each file is complete with the required forms. LPA obtained a copy of the children's roster.

Three staff files were reviewed. All teachers and staff maintain valid background clearances. All staff files reviewed contain the required transcripts/verification of experience. All staff have updated CPR and First Aid certification and Mandated Reporter Training. Director 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). All staff have the required immunization's for measles, pertussis and influenza or a statement declining the vaccine.

Director 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.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

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: BELLGRAD EVERGREEN STEM ACADEMY	FACILITY NUMBER: 434417300
	VISIT DATE: 03/05/2026

NARRATIVE

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LPA reminded Director that no child(ren) shall be left without the supervision of a teacher at any time and supervision shall include visual observation.

Incidental Medical Services (IMS) policy was discussed. Director states that no children require medications or IMS at this time. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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: https://www.ada.gov/resources/child-care-centers/

Director stated that any medications at the facility will be stored in child locked or high cabinets out of reach of children. Isolation of sick child was discussed, and Director stated that sick children will be isolated in the classroom with other children in the outdoor area or in the school office if it is open until parent pick up.

Facility does not provide transportation to children. Director 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 Director, Ronit Rose.

No deficiencies were cited as 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.

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

LIC809 (FAS) - (06/04)

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