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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400285
Report Date: 06/19/2024
Date Signed: 06/19/2024 09:41:19 PM

Document Has Been Signed on 06/19/2024 09:41 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:SAN JOSE DAY NURSERY INFANT/TODDLER PROGRAMFACILITY NUMBER:
434400285
ADMINISTRATOR/
DIRECTOR:		ELENA JOLLYFACILITY TYPE:
830
ADDRESS:33 N. 8TH STREETTELEPHONE:
4082889667
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 20DATE:
06/19/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:Angela GomezTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Andrea Cortez and Anna Morales conducted an unannounced Annual Inspection and was greeted by Executive Director Angela Gomez. LPAs toured the facility both inside and outside during today’s visit. 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), and Activity Schedules. Last disaster drill was conducted on 04/01/2024

The infant program is located in the backyard portable classroom, separate from the Preschool. LPAs observed a total of 20 infant/toddlers. There were seven (7) staff present( 2 qualified teachers and 5 aides) . The teacher/child ratio was in compliance during today’s visit. LPAs observed the classroom is clean and safe for children. The changing table is within arms reach of a sink. All furniture observed to be in good condition and safe for the children. The program uses mats and cribs for children to nap. Outdoor activity spaces are enclosed by fencing and are observed to be free of hazards. LPAs observed play equipment were in good condition. Drinking water was readily available to children indoor and outdoor. Facility provides lunch and snacks (morning and afternoon). Lunch and snacks are prepared at the facility. LPAs observed that food storage areas were clean and free of litter. LPAs observed that each infant has current feeding, diaper, and nap log. The center has documentation that sleeping infants were checked every 15 minutes. Diapers are being disposed appropriately. Each infant has personal items individually stored and labeled.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SAN JOSE DAY NURSERY INFANT/TODDLER PROGRAM
FACILITY NUMBER: 434400285
VISIT DATE: 06/19/2024
NARRATIVE
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There were no bodies of water observed. Director stated that the facility do not have weapons on the premises. Furniture and equipment were observed to be age appropriate and in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, and other items that are dangerous to children were stored inaccessible to children. Floors were clean. Trash cans for solid waste had tight-fitting covers on, and were in good repair. Fire extinguisher, smoke and carbon monoxide detectors were observed. (hardwired system).

This facility is providing Incidental Medical Services – IMS Plan. Director stated that none of the children currently enrolled are using medication Center has an isolation area for sick infants to wait for parent pick up.

LPAs reviewed sign in and out record on Pro Care Application. A sampling of children and staff files was taken for review during today's inspection. Children records reviewed include Emergency Contact, Consent for Emergency Medical Treatment, Personal Rights Notice, Medical Assessment, Immunization, and Infant Needs and Services Plan.

Multiple staff records reviewed include Criminal Record and Child Abuse Index Clearance, Health Screening Report and TB test, Immunization (Measles, Pertussis, and Flu) are incomplete or expired. LPAs reminded Director the online AB1207 Mandated Reported Training needs to be renewed every two years. No staff have current certification in Pediatric CPR and First Aid in the infant side of the facility.

LPAs reminded Director of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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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: SAN JOSE DAY NURSERY INFANT/TODDLER PROGRAM
FACILITY NUMBER: 434400285
VISIT DATE: 06/19/2024
NARRATIVE
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LPA discussed the requirements of AB 633 with the Licensee. The Director understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Director and advised the Director of the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

No Deficiencies were cited at today's visit.

NOTICE OF SITE VISIT WAS ISSUED. EXECUTIVE DIRECTOR WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/19/2024 09:41 PM - It Cannot Be Edited


Created By: Andrea Cortez On 06/19/2024 at 03:46 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: SAN JOSE DAY NURSERY INFANT/TODDLER PROGRAM
FACILITY NUMBER: 434400285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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4
Based on record review, the licensee did not comply with the section cited above in S2, S3, and S5, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Director to email LPA proof of staff immunizations by 7/19/2024
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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Based on record review, the licensee did not comply with the section cited above. No staff have current pediatric cardiopulmonary resuscitation and pediatric first aid which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Director to email LPA proof of CPR training by 7/19/2024
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:Andrea Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/19/2024 09:41 PM - It Cannot Be Edited


Created By: Andrea Cortez On 06/19/2024 at 03:46 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: SAN JOSE DAY NURSERY INFANT/TODDLER PROGRAM
FACILITY NUMBER: 434400285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. S1,S2, and S3 do no have current record of TB clearance. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Director to email proof of TB by 7/19/204
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. S2, S3, and S5 did not have current health-screening report. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Dirctor to email proof of health-screening report to LPA by 7/19/24
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:Andrea Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/19/2024 09:41 PM - It Cannot Be Edited


Created By: Andrea Cortez On 06/19/2024 at 04:34 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: SAN JOSE DAY NURSERY INFANT/TODDLER PROGRAM
FACILITY NUMBER: 434400285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)

Provide training including statewide guidance on the responsibilities of a mandated reporter who is a licensed day care provider or an applicant for that license, administrator, or employee of a licensed child day care facility in accordance with the Child Abuse and Neglect Reporting Act (Article 2.5 (commencing with Section 11164) of Chapter 2 of Title 1 of Part 4 of the Penal Code). The department shall provide the guidance using its free module or modules provided on the State Department of Social Services Internet Web site or as otherwise specified by the department. This guidance content shall include, but is not necessarily limited to, all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Staff are S1,S3, S4, and S6 don not have current Mandated Reporter on file. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Director to email LPA proof of Mandated Reporter training by 7/19/24
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Andrea Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


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