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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413426
Report Date: 11/03/2023
Date Signed: 11/03/2023 12:24:58 PM

Document Has Been Signed on 11/03/2023 12:24 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:TULIP KIDS ACADEMYFACILITY NUMBER:
434413426
ADMINISTRATOR:EVANGELINE PONCEFACILITY TYPE:
850
ADDRESS:1159 WILLOW AVENUETELEPHONE:
(408) 340-7993
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 67TOTAL ENROLLED CHILDREN: 50CENSUS: 36DATE:
11/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Evangeline PonceTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mel Matos met with Evangeline Ponce, director, for an unannounced case management inspection. LPA toured the Facility during today's inspection.

LPA observed nine napping mats in Room 1 (Jr Preschool Room) during today's inspection that have exposed foam. The mats with exposed foam present a potential risk to the health, safety, or personal rights of children in care. Evangeline Ponce, director, removed the mats from Room 1 (Jr Preschool Room) during today's inspection.

Evangeline states that the Facility will order extra mats to have on site. Evangeline also states that the Facility will implement a plan to inspect all mats at least once per month to ensure that the napping mats are maintained in a safe condition at all times.

A "Type B" deficiency is being cited on the attached LIC 9099-D. Exit interview conducted and report was reviewed with Director, Evangeline Ponce. Appeal rights was also provided to Evangeline prior to conclusion of today's inspection.

Notice of site visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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Document Has Been Signed on 11/03/2023 12:24 PM - It Cannot Be Edited


Created By: Melvin S Matos On 11/03/2023 at 11:45 AM
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: TULIP KIDS ACADEMY
FACILITY NUMBER: 434413426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2023
Section Cited
CCR
101239.1(a)

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Napping Equipment: Cots used for napping shall be maintained in a safe condition. This requirement was not met as evidenced by: LPA Matos observed nine napping mats in Room 1 (Jr Preschool Room) during today's inspection that have exposed foam.
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Evangeline Ponce, director, agreed to order extra napping mats and to implement a plan to inspect all mats at least once per month to ensure that the napping mats are maintained in a safe condition at all times.
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Evangeline Ponce, director, removed the nine napping mats from Room 1 (Jr Preschool Room) during today's inspection. This presents a potential risk to the health, safety, or personal rights of children in care.
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A written Plan of Correction is due to LPA Matos by Monday November 6, 2023.

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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:Diana Stephenson
LICENSING EVALUATOR NAME:Melvin S Matos
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
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