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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415464
Report Date: 09/24/2025
Date Signed: 09/24/2025 03:06:48 PM

Document Has Been Signed on 09/24/2025 03:06 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:PACIFIC GROVE ADULT EDUCATION CDCFACILITY NUMBER:
274415464
ADMINISTRATOR/
DIRECTOR:		BARBARA MARTINEZFACILITY TYPE:
850
ADDRESS:1025 LIGHTHOUSE AVENUETELEPHONE:
(831) 646-6623
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 27DATE:
09/24/2025
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Jennifer HallTIME VISIT/
INSPECTION COMPLETED:
03:24 PM
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On September 24, 2025, Licensing Program Analyst (LPA) Darnella Barnes conducted an unannounced annual inspection. The purpose of the visit was explained to Director Jennifer Hall, who granted access to the facility and received the Entrance Checklist (LIC 125)

The facility operates Monday – Friday 7:00am – 5:30pm, Required postings were visible to the public, and the last fire drill was completed on 8/29/25. Director was reminded of the six-month drill and documentation requirement. A fully charged 3A-40B-C fire extinguisher, was last serviced on 6/19/25 is available, along with working smoke and carbon monoxide detectors, and an operating telephone.Director was reminded that smoking is prohibited. Directorr confirmed there are no firearms on the property.

Director, 2 teachers, 5 teacher aides and 27 children were present, meeting capacity and ratio requirements. Staff were attentive, actively engaged with children, and present in sufficient numbers to ensure proper supervision. Director is aware of the child illness regulation.

Fingerprint clearances for individuals at this facility who require caregiver background checks are issued by State Department and/or County Office of Education and do not come under the jurisdiction of Community Care licensing Division.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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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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: PACIFIC GROVE ADULT EDUCATION CDC
FACILITY NUMBER: 274415464
VISIT DATE: 09/24/2025
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Inside the facility, the environment was clean, safe, and well-maintained. The flooring was in good condition and free from tripping or slipping hazards. Toy containers had smooth corners, proper ventilation, and no finger-trapping lids. Children were protected from slipping risks, and each had a clearly marked space for storing personal items. LPA observed diaper changing table within arm's reach of a sink.

This facility does not provide regular meals or snacks. Each child is expected to bring two snacks, a packed lunch, and a personal water bottle each day. Families are responsible for ensuring that all food meets their child’s dietary needs and is appropriately packed. A filtered water system is available in the kitchen, and teachers will refill water bottles as needed to keep children hydrated. While daily food and drink must be brought from home, the preschool maintains a supply of snacks and water, which may be provided if a child needs additional nourishment during the day

LPA Barnes observed that the cots are made of wipeable material and are cleaned daily or more often as needed. During naptime, children were resting on cots spaced with walkways in between, allowing for safe movement and easy access.

Cleaning products and chemicals were securely stored in a locked cabinets and storage room, inaccessible to children and separate from food areas. Floors were cleaned daily, with mopping and carpet vacuuming using disinfectants that were properly discarded. Trash was kept in covered containers, and the indoor temperature was maintained at 68°F.

Bathroom facilities met the required ratio of one sink and toilet per 15 children. Toileting areas, including sinks, dispensers, walls, and floors, were routinely disinfected. The designated sink for rinsing soiled items was sanitized after each use.

LPA Barnes reviewed 5 children's files. All files were complete and included the Admission Agreement, Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Physician's Report (LIC 701), immunization records, Personal Rights (LIC 613A), Notification of Parent’s Rights (LIC 995A), and Child's Pre-admission Health History. LPA reviewed facility roster, sign-in/out and completed using full legal signatures and recorded times.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PACIFIC GROVE ADULT EDUCATION CDC
FACILITY NUMBER: 274415464
VISIT DATE: 09/24/2025
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In addition, LPA Barnes reviewed seven staff files (S1–S7). Each file included current Pediatric First Aid/CPR and Mandated Reporter Training certificates, Personnel Record (LIC 501)/job application, Health Screening Report (LIC 503), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), Employee Rights (LIC 9052) and Education requirements. Files also showed proof of TB clearance, immunization records (pertussis, measles, influenza or declination of influenza).

The Licensing Program Analyst (LPA) reminded the Director that Mandated Reporter Training must be renewed every two years. The LPA also emphasized that at least one staff member with current CPR/First Aid certification must be present at all times. Additionally, aides and assistants must remain under the direct supervision of a qualified teacher, except during nap time and when escorting children to the bathroom

First aid supplies were accessible to staff and kept out of children's reach. The kit contained a manual, bandages, scissors, tape, thermometer, tweezers, and antiseptic solution.

Incidental Medical Services (IMS) policy was discussed. 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/.



During the outdoor inspection, LPA observed that all walkways, ramps, and stairs were free of tripping hazards. The play area was shaded, well-organized, and clear of debris or dangerous items. Climbing structures and slides had protective turf landing. Outdoor equipment was age-appropriate, securely anchored, in good condition, and free of sharp edges or loose parts. When playing outside, children brought their own water bottles. The facility offered filtered water for refills when needed The outdoor area was fully enclosed by a fence at least four feet high, with no dangerous equipment present

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: PACIFIC GROVE ADULT EDUCATION CDC
FACILITY NUMBER: 274415464
VISIT DATE: 09/24/2025
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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. For child care center licenses issued after July 1, 2022, the Site Supervisor shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

This facility, however, was constructed on August 17, 2017, as indicated in the approved building plans filed with the Division of the State Architect, State of California Job #17093. As such, it is not subject to the mandatory lead testing requirement for buildings constructed prior to January 1,2010.

LPA discussed the safe sleep regulations with Director and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and- resources/safe-sleep, as an additional resource. LPA also informed Site Supervisor of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Director was informed of the MyChildCarePlan.org site, 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.



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 inspection the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

No deficiency issued during today's inspection. A notice of site visit was given and must remain posted for 30 days. Appeals rights provided.
Exit interview conducted and report was reviewed with the Director Jennifer Hall

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC809 (FAS) - (06/04)
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