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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415418
Report Date: 10/19/2022
Date Signed: 10/19/2022 07:44:28 PM

Document Has Been Signed on 10/19/2022 07:44 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:JARDIN DE MARIPOSAS SCHOOLFACILITY NUMBER:
434415418
ADMINISTRATOR:MELISSA GRANEYFACILITY TYPE:
850
ADDRESS:26790 ARASTRADERO ROADTELEPHONE:
(650) 796-6807
CITY:LOS ALTOS HILLSSTATE: CAZIP CODE:
94022
CAPACITY: 60TOTAL ENROLLED CHILDREN: 44CENSUS: 27DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Melissa GraneyTIME COMPLETED:
02:45 PM
NARRATIVE
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On 10/19/2022 at 10:15am, Licensing Program Analyst (LPA) Christina Uribe conducted an Unannounced Annual Required Inspection. LPA met with Site Director, Melissa Graney, also present at the time of the inspection were 6 staff & 27 children. The facility is within ratio & capacity compliance today. LPA provided facility representative the Entrance Checklist (LIC 125). The facility was toured to conduct a Health and Safety inspection. The facility currently operates 8:30am-4:30pm, Monday-Friday in 5 classrooms.

Classrooms: All classrooms were inspected for age-appropriate furnishings, equipment, & adequate storage for children’s belongings. LPA observed the cleanliness of floors & surfaces, the presence of a fully functional carbon monoxide detector, smoke detector/fire alarms, and a fully charged 3A40BC fire extinguisher that is accessible throughout the facility. The center is equipped with a fully stocked first-aid kit and available in the classrooms.

Food Service Areas: All center provided food items are properly labeled & stored separately from cleaning supplies. Food prep area is clean, adequately equipped, & free from hazardous materials. Snack menu is posted one week in advance, available for review, & dated. Solid waste bins are equipped with tight fitting lid.

Bathrooms: Toilets and faucets are in safe and sanitary operating condition. The children are able to reach the sinks and toilets. Supplies are available to children.

Outdoor Play Area: There are no bodies of water, or free-standing water accessible to children. There are age appropriate toys and materials for the children. The playground outside is fenced and all equipment and surfaces are free from hazards.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: JARDIN DE MARIPOSAS SCHOOL
FACILITY NUMBER: 434415418
VISIT DATE: 10/19/2022
NARRATIVE
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Records: All individuals subject to criminal record review have a clearance and have been associated to the facility. LPA reviewed 5 children’s files and 6 staff files. LPA reviewed the facility roster & personnel record. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Mandated Reporter certificates were reviewed. Director’s CPR/First-Aid Certificate is current and expires on 08/20/24. The center is in compliance with sign in and out procedure. Emergency Drills are recorded and performed every six months. Per facility representative, there are no firearms on the premises. All required documents are posted in a publicly accessible area.

Health-Related Services: This facility does provide Incidental Medical Services (IMS). LPA inspected storage of medications and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations & Procedures for Child Care Centers sections 101173 & 101226. 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

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/process.

DIrector was reminded that all adults 18 and over, 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.

Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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Document Has Been Signed on 10/19/2022 07:44 PM - It Cannot Be Edited


Created By: Christina Uribe On 10/19/2022 at 01:16 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: JARDIN DE MARIPOSAS SCHOOL
FACILITY NUMBER: 434415418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101226(e)(3)(B)
Health-Related Services
(3) Prescription medications may be administered if all of the following conditions are met: (B) For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child.

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 as several children did not have a signed consent for administration of medication form with their medication which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Director will obtain a signed copy of a consent for medicaiton administration form for each child's prescription and non-prescription medication and email copies of these forms to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 11/18/22.
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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022


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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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: JARDIN DE MARIPOSAS SCHOOL
FACILITY NUMBER: 434415418
VISIT DATE: 10/19/2022
NARRATIVE
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Deficiencies & Advisory Notes Issued Today: Please see attached Deficiency & Advisory Note pages for additional information.
  • Type B Violation: Several children did not have a signed parent consent for administration of medication form with their medication.
  • Type B Violation: Two staff members did not have proof of immunity against Measles (MMR) and Pertussis (Tdap).
  • Type B Violation: Two staff members did not have proof of TB Clearance.
  • Technical Violation: Two staff members did not have a current Mandated Reporter certification.
  • Technical Violation: Two staff members did not have a Health Screening Report (LIC 503) form.
  • Technical Violation: Some children's Identification & Emergency (LIC 700) forms were missing their physician and dentist information to be called in an emergency.
  • Technical Violation: One child's Identification & Emergency (LIC 700) form was missing additional persons to be called in an emergency.
  • Technical Violation: One child's medication was missing it's original packaging/container with prescription label.
  • Technical Violation: Facility either needs to use Facility Roster (LIC 9040) form or update their own form to include the exact same information as the licensing form (LIC 9040) including the child's exact start date, the name and phone number of child's physician.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were given and reviewed. Exit interview conducted and report was reviewed with the director, Melissa Graney.

Page 3 of 3 ***End of Report***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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Page: 3 of 11
Document Has Been Signed on 10/19/2022 07:44 PM - It Cannot Be Edited


Created By: Christina Uribe On 10/19/2022 at 01:16 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: JARDIN DE MARIPOSAS SCHOOL
FACILITY NUMBER: 434415418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022

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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Based on interview & record review, the licensee did not comply with the section cited above as two staff members do not have proof of immunization for Measles (MMR) and Pertussis (Tdap) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Staff will obtain proof of immunization to Measles (MMR) and Pertussis (Tdap) and Director will email these records to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 11/18/22.
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above in as two staff members did not have proof of TB Clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Staff will obtain proof of TB Clearance and Director will email these records to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 11/18/22.
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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022


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