434414755-8-27-2024-07-CC-FRAA-D8JM4F-20240827091640

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414755
Report Date: 08/26/2024
Date Signed: 08/27/2024 09:16:49 AM

Document Has Been Signed on 08/27/2024 09:16 AM - 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	EVERGREEN MONTESSORI SCHOOL - AR		FACILITY NUMBER:	434414755
ADMINISTRATOR/ DIRECTOR:	PRAKASH, SUNITA		FACILITY TYPE:	850
ADDRESS:	3000 ABORN ROAD		TELEPHONE:	(408) 603-5000
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY: 50	TOTAL ENROLLED CHILDREN: 21	CENSUS: 20	DATE:	08/26/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:54 AM
MET WITH:	Sunita Prakash		TIME VISIT/ INSPECTION COMPLETED:	02:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/26/2024 at 10:54am, Licensing Program Analyst (LPA), Farida Raja, met with Director, Sunita Prakash for an unannounced Annual/Random inspection. The facility is licensed to serve children ages 2 years to entry into first grade. LPA observed the required posted materials in the lobby, monthly menu in the kitchen and daily activity schedule and activity plan in each classroom. Days and hours of operation are Monday through Friday, 7:30 AM to 6:00 PM. Director informed LPA that they are in the process of sale of business and will continue to operate the facility until the new owners obtain their child care center license. LPA and staff, Sandhya Panchagni toured the indoor and outdoor areas of the facility during today's inspection and observed the following ratios: Room 1 (Cypress): 9 children and 2 teachers Room 2 (Juniper): 11 children and 3 teachers Facility was in compliance with teacher to children ratio requirement during today's inspection. Classrooms, children's restrooms which are shared between the two classrooms, staff restroom, kitchen, lobby and office area were inspected. Children were engaged in circle time and under supervision of staff. Facility has central heating/cooling for comfort of children. Director states that there are no weapons or firearms on the premises. There is a working telephone at the facility (408-238-9001). Disinfectants and cleaning products were stored inaccessible to the children in care. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. LPA observed solid waste containers with tight-fitting lids in the rooms. Restrooms and sinks for children were observed to be safe, sanitary, and in working condition. Staff has one separate bathroom that can be utilized by sick children if needed. LPA observed fire extinguishers, working smoke and carbon monoxide detectors, and fire pull stations. The facility has a built-in smoke detector/ fire system. Log shows that the last Fire Drill was conducted on 08/21/2024 which is compliant with the six-month requirement for facilities. Continued on Page 2

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: EVERGREEN MONTESSORI SCHOOL - AR	FACILITY NUMBER: 434414755
	VISIT DATE: 08/26/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Drinking water is readily available for children in each room via individual water bottles and water pitcher and disposable cups.

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.

Director stated that the building was built after 01/01/2010. LPA requested Director to submit proof showing building was constructed after January 1, 2010 to the Department by 09/09/2024.

Facility does provide meals and snacks to the children in care. Parents are allowed to provide meals and snacks as well. Menu was observed to be posted in the kitchen area. Food and beverages were stored safely to prevent contamination and spoilage. Food storage and preparation areas were observed to be sanitary.

Outdoor playground and play equipment was inspected and observed to be fenced in and free of hazards. LPA observed play equipment was in good condition and age-appropriate. Areas around and under high climbing equipment and slides were cushioned with resilient material. Shade is provided by canopies. There were no bodies of water observed. Drinking water is provided outdoors via water fountains.

Children's roster was reviewed, and a copy was provided to the LPA. A sampling of six (6) children’s files were reviewed during today's inspection. Each child's file reviewed contained the required forms.

LPA reviewed three (3) staff files. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. All staff files reviewed contain the required transcripts/verification of experience. At least one staff member on site has a current CPR and First Aid certification. Director 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 (field trips). LPA observed required Mandated Reporter Training on file for all staff. LPA reviewed staff immunization's and observed that staff, S2 does not have proof of immunization's for measles, pertussis, influenza or a statement declining the vaccine and staff, S3 does not have proof of measles and pertussis immunization's.

Continued on Page 3

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: EVERGREEN MONTESSORI SCHOOL - AR	FACILITY NUMBER: 434414755
	VISIT DATE: 08/26/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Director 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 per person will be assessed if this regulation is violated.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. Facility has an approved IMS Plan on file in the San Jose Regional Office. For IMS information see PIN 22-02-CCP. Medications at the facility are stored in each classroom out of reach of children. Isolation of sick child was discussed, and Director explained that sick children will be isolated in the director's office and isolation equipment will be provided. A staff restroom which is off limits to other children is used if necessary. Child is always under visual supervision while in care of the facility.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Facility does not provide transportation to children, but Director understands that children cannot be left alone, unattended in parked vehicles.

Director was informed of the MyChildCarePlan.org website; 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.

Two Type B deficiencies were cited as a result of today's inspection. Appeal rights provided. Exit interview conducted and report was reviewed with Director, Sunita Prakash.

NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

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

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/27/2024 09:16 AM - It Cannot Be Edited

Created By: Farida Raja On 08/26/2024 at 01:45 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: EVERGREEN MONTESSORI SCHOOL - AR	FACILITY NUMBER: 434414755
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

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
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above for two staff (S2 and S3) which poses a potential health, safety or personal rights risk to persons in care. LPA reviewed staff immunization's and observed that staff, S2 does not have proof of immunization's for measles, pertussis, influenza or a statement declining the vaccine and staff, S3 does not have proof of measles and pertussis immunization's.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Director to submit proof of immunizations for two staff, S2 and S3 to LPA by POC due date of 09/09/2024.

Type B

Section Cited

CCR

101226(e)(3)(A)

Health-Related Services

(3) Prescription medications may be administered if all of the following conditions are met: (A) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above for child, C6, which poses a potential health, safety or personal rights risk to persons in care. LPA observed child's (C6) Epinephrine Autoinjector is expired and has not been returned or renewed by facility.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Director shall submit a written plan of how the center will check expiration dates on medications and request renewal or return expired medication to authorized representatives. Director will return C6s medication and obtain new medication for the child in care. Director will send proof of correction to LPA by 09/09/2024.

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:

Farida Raja

LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4