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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444417036
Report Date: 04/22/2024
Date Signed: 04/22/2024 01:56:35 PM

Document Has Been Signed on 04/22/2024 01:56 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:MIDTOWN MONTESSORIFACILITY NUMBER:
444417036
ADMINISTRATOR/
DIRECTOR:		JOACHIM WILLIAMSFACILITY TYPE:
850
ADDRESS:987 BOSTWICK LANE, CLASSROOM 1TELEPHONE:
(831) 423-2273
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 25TOTAL ENROLLED CHILDREN: 26CENSUS: 20DATE:
04/22/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Kalai HerrickTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Jessica Bongardt met with Kalai Herrick ,Head Teacher, for an unannounced Required - 1 Year inspection. LPA toured the indoor and outdoor areas of the Facility with Kalai during today's inspection. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), menus, and Activity Schedule. Days and hours of operation are Monday-Friday 8:30AM to 5:00PM. The facility is licensed to serve a maximum of 25 children.

LPA reviewed five children's and five staff files during today's inspection. Each child's file reviewed did not contain all required forms/documents, including Admission Agreement, Emergency Medical Consent (LIC 627), and Information and Emergency Information form (LIC 700). All staff files reviewed did not contain the required forms/documents, including transcripts/verification of experience/immunization records, and Health Screening Report (LIC 503). All files reviewed did not have current Mandated Reporter Certificates on file. Facility does not have any staff with current CPR and First Aid certifications on file. Head Teacher 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. Last fire/disaster drill was completed on 01/12/2024.

LPA observed that the teacher/child ratio was complying during today's inspection. LPA observed 20 children an 4 staff during today's inspection. Kalai understands the conditions, limitations, and capacity specifications of the facility license. Head Teacher understands that children shall be always visually supervised. If a child comes to the facility who exhibit symptoms of illness including, but not limited to, fever or vomiting, they are not accepted into care. Any children who become ill during the day, shall be isolated on the couch in the office area while they wait for a parent/guardian to come and pick them up.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: MIDTOWN MONTESSORI
FACILITY NUMBER: 444417036
VISIT DATE: 04/22/2024
NARRATIVE
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Head Teacher understands that children's personal rights should not be violated, including no unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature.

LPA observed that the facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. Kalai states that the facility has janitorial service from the school and understands that the facility must be kept free of flies and other insects & rodents. LPA observed that all furniture and equipment is in good condition and safe for the children. Drinking water is made available to the children by reusable water bottles that are brought from home. There are water dispensers in the classroom that the children can refill their water bottles from.

LPA observed there is hot and cold running water and a refrigerator on the premises. The facility does provide PM snack for the children, AM Snack and Lunch are brought from home. The Facility has trash cans with tight fitting lids for solid waste in the classrooms. Cleaning supplies are inaccessible to the children and stored in cabinets located in areas off limits to children. LPA observed a complete first aid kit available in the facility. The facility has a working integrated fire alarm system with the school and carbon monoxide detectors. There is one 2-A-10-BC fire extinguisher located in the facility. There are no weapons located at the facility.

The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. There is a waiver in place for shared space with the Chrysalis Program that occupies the same building. The facility understands the waiver and knows that the two programs are not to commingle. LPA observed that the outdoor equipment is age appropriate and in good condition. Shade rest areas are provided by overhang off the building and umbrellas that can be opened. There are sufficient resilient materials on the outdoor playground area. LPA did not observe any bodies of water. Head Teacher states that the facility does provide transportation for preschool children only on field trips.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
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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: MIDTOWN MONTESSORI
FACILITY NUMBER: 444417036
VISIT DATE: 04/22/2024
NARRATIVE
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 * Head teacher 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/$3000.00 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 childcare 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).

This facility does not provide Incidental Medical Services – IMS at this time. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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: http://www.ada.gov/childqanda.htm

Please update all the facility forms (Employee and Children's) to reflect your correct facility number.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
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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: MIDTOWN MONTESSORI
FACILITY NUMBER: 444417036
VISIT DATE: 04/22/2024
NARRATIVE
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LPA informed Head Teacher, Kalai Herrick, that this report dated 04/22/2024 documents one Type A citations, which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA informed the Head Teacher to provide a copy of this licensing report dated (04/22/2024) that documents one Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

As a result of today's inspection, 8 deficiencies have been cited, see attached LIC9099-D's. Appeal Rights were given.

Exit interview conducted and report was reviewed with the Head Teacher, Kalai Herrick.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST BE POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
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Document Has Been Signed on 04/22/2024 01:56 PM - It Cannot Be Edited


Created By: Jessica Bongardt On 04/22/2024 at 12:19 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: MIDTOWN MONTESSORI
FACILITY NUMBER: 444417036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in which Staff 1-4 did not poses current Mandated Reporter Certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2024
Plan of Correction
1
2
3
4
Staff will complete Mandated Reporter Training and submit the certificates to the department by the plan of correction date.
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 the licensee did not comply with the section cited above staff 1, 3, 4, 5, did not have immunization records on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
1
2
3
4
Staff will obtain their immunization records and flu shot or declination of the flu shot and submit them to the department by the plan of correction date.
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:Belinda Devall
LICENSING EVALUATOR NAME:Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


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Document Has Been Signed on 04/22/2024 01:56 PM - It Cannot Be Edited


Created By: Jessica Bongardt On 04/22/2024 at 12:19 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: MIDTOWN MONTESSORI
FACILITY NUMBER: 444417036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101215.1(m)
Child Care Center Director Qualifications and Duties
(m) A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2024
Plan of Correction
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2
3
4
The director of the facility will complete the preventative health and safety including lead class or show proof of enrollment to the department by the plan of correction date.
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above none of the staff have current CPR/First Aid certificates on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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At least one staff that is on-site at all times will complete CPR/First aid and submit it to the department by the plan of correction date.
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:Belinda Devall
LICENSING EVALUATOR NAME:Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


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Document Has Been Signed on 04/22/2024 01:56 PM - It Cannot Be Edited


Created By: Jessica Bongardt On 04/22/2024 at 12:19 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: MIDTOWN MONTESSORI
FACILITY NUMBER: 444417036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above Staff 3 has not completed any employment paperwork which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
1
2
3
4
Licensee/Director will have Staff 3 complete all necessary paperwork for employment and then will submit the proof to the department by the plan of correction date.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above Child 3 & Child 5 do not have current Physician Reports on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2024
Plan of Correction
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2
3
4
Licensee/Director will have the parents of Child 3 and Child 5 obtain a Physicians Report for the child and the Licensee/Director will submit a copy to the department by the plan of correction date.
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:Belinda Devall
LICENSING EVALUATOR NAME:Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


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Document Has Been Signed on 04/22/2024 01:56 PM - It Cannot Be Edited


Created By: Jessica Bongardt On 04/22/2024 at 12:19 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: MIDTOWN MONTESSORI
FACILITY NUMBER: 444417036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220.1(a)
Immunizations
(a) Prior to admission to a child care center, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, commencing with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above Child 3 does not have a current immunization record on file and Child 4's immunizations are not up to date which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2024
Plan of Correction
1
2
3
4
Licensee/Director will have parents obtaine copies of current immunization records or schedule immunizations and provide the documentation to the facility. Licensee/Director will submit that documentation to the department by the plan of correction date.
Type B
Section Cited
HSC
1597.16(a)(1)
(a) (1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
Licensee/Director will schedule someone to come at test the lead in the water and have a written plan and dates of the testing submitted to the department by the plan of correction date.
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:Belinda Devall
LICENSING EVALUATOR NAME:Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


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Document Has Been Signed on 04/22/2024 01:56 PM - It Cannot Be Edited


Created By: Jessica Bongardt On 04/22/2024 at 12:53 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: MIDTOWN MONTESSORI
FACILITY NUMBER: 444417036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(2)
101170(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f)

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above with Staff 1, 4, and 5 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
1
2
3
4
Licensee/Director will associate all individuals working for the facility to the correct facility number by using Guardian and submit proof to the department by the plan of correction date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Belinda Devall
LICENSING EVALUATOR NAME:Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


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