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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415601
Report Date: 04/13/2023
Date Signed: 04/13/2023 04:37:43 PM

Document Has Been Signed on 04/13/2023 04:37 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PEPPERTREE SCHOOLS RANCH HOUSEFACILITY NUMBER:
434415601
ADMINISTRATOR:DANNA D MATTHEW OSBORNFACILITY TYPE:
850
ADDRESS:14969 LOS GATOS ALMADEN ROADTELEPHONE:
(408) 626-9200
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY: 24TOTAL ENROLLED CHILDREN: 21CENSUS: 17DATE:
04/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Danna OsborneTIME COMPLETED:
05:00 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Kassandra Medrano conducted a Case Management inspection today. LPA met with Danna Osborne, Site Director the purpose of the visit was explained. During tour of the facility with director, at 3:25pm it was observed that two spray bottles of cleaning products, one being bleach were left on child's table and were accessible to children for approximately 5 minutes. When LPA discussed observation staff immediately moved the cleaning products and put them out of reach.

Exit interview conducted and report was reviewed with the facility representative, Dana Osborne.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):

"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS. LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH APPLICANT/PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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 04/13/2023 04:37 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 04/13/2023 at 03:49 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: PEPPERTREE SCHOOLS RANCH HOUSE
FACILITY NUMBER: 434415601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/14/2023
Section Cited
CCR
101238(g)(1)

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101238 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.(1) Storage areas for poisons shall be locked.
The requirement was not meant as evidenced by:
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Staff immediatley moved cleaning products, and director to send documentation of training for staff.
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During tour of facility at 3:25pm it was observed in classroom 2 that facility did not ensure that cleaning products were locked and made inaccesible to children. This posed an immediate risk to children in care
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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:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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