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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444417043
Report Date: 10/17/2022
Date Signed: 10/17/2022 02:35:23 PM

Document Has Been Signed on 10/17/2022 02:35 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SPROUTS SC TIERRA PACIFICAFACILITY NUMBER:
444417043
ADMINISTRATOR:JORDAN BEMELFACILITY TYPE:
840
ADDRESS:986 BOSTWICK LANE ROOMS 1 & 7TELEPHONE:
(831) 462-9404
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 50TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
10/17/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Jordan Bemel TIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPAs), Marilou Monico and Elizabeth Berumen, conducted an announced pre-licensing inspection to the Facility today. LPAs met with Applicant Representative, Jordan Bemel, and explained the nature of today's inspection. The Applicant has applied for a school age license in Rooms 1 and room 7 on the campus of Tierra Pacifica Charter School. The school age program will operate Monday thru Thursday 1:30-6:00 PM and on Fridays from 12:00 PM to 6:00 PM.

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 was submitted to Licensing, room 7 can occupy 122 students and room 1 can occupy 30 students.

LPAs toured Room 1 and 7 as well as the playground areas and bathrooms during today's visit. There are 5 toilets and 3 urinals (105) and 7 sinks (105) available for the children. LPAs observed 91 chairs, 23 tables, 54 cubbies, and 54 hooks. LPAs observed trash cans with tight fitting lids and adequate equipment, furniture, and supplies for the children.

The children’s bathrooms are located on the side of room 4 and allow for individual privacy. Staff have designated bathrooms in the office a sick child will use one of the staff bathrooms if needed. Sick child will be isolated in main office and escorted and supervised by staff. The main office is located next to room 1.

LPAs did not observe any fireplaces or wall heaters at the Facility. Room 1 and 7 have appropriate lighting and ventilation (central heating/air conditioning). First aid supplies are stored in Room 1 and 7 inaccessible to children. The carbon monoxide and smoke detectors in both rooms were tested and proved to be functioning. LPAs observed a 3A40BC fire extinguisher. Applicant representative states there are no weapons on the premises.

Report continued on page 2:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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: SPROUTS SC TIERRA PACIFICA
FACILITY NUMBER: 444417043
VISIT DATE: 10/17/2022
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The Facility will only provide snacks for the school age children. There is a food preparation area in the Room 7. The food preparation area is equipped with stove, oven, microwave, refrigerator, and a sink with cold water only. Jordan stated that there is a work order that has been placed to turn the hot water on. Disposables dishes and utensils will be used to serve snacks to the children. Drinking water is provided via a combination of water fountains and water dispensers both indoors/outdoors. Cleaning supplies will be stored in locked cabinet under the sink in the classroom 7. Transportation will not be provided by the Facility.

The program will utilize the playground located behind room 7; the playground has age appropriate climbing structures and sufficient wood chips as resilient material. The school age program will use the playground after elementary school hours. Shade is provided by trees, building overhang and outdoor pergola. There is adequate equipment and supplies for children outdoors. LPAs did not observe any bodies of water.

LPAs discussed Senate Bill 792, AB 633, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years with Applicant. Licensing forms, Title 22 regulations, can be obtained through the internet at ww.ccld.ca.gov. Mandated Reporter Training can be accessed at www.mandatedreporterca.com.

Beginning January 1, 2019 AB 2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPAs provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility. LPAs advised Jordan that for a license issued on or after July 1, 2022, initial testing results for lead shall be received and posted within 180 days of licensure.

Incidental Medical Services (IMS) policy was discussed with the Applicant. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm. The Applicant states that he does not plan on administering medication to children at this time.

Report continued on page #3:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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: SPROUTS SC TIERRA PACIFICA
FACILITY NUMBER: 444417043
VISIT DATE: 10/17/2022
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Applicant 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.

LPAs reviewed with Applicant Representative 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 Jordan Bemel, Applicant Representative. LPAs advised Jordan that a license for 50 school age children will be submitted to Licensing Management for the final stage of approval upon receiving the following items:

1) Approved fire clearance for 50 school age children.

2) Proof that hot water is available in the food preparation area located in Room 7.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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