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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415603
Report Date: 02/05/2025
Date Signed: 02/05/2025 12:55:27 PM

Document Has Been Signed on 02/05/2025 12:55 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:PEPPERTREE SCHOOLS COTTAGE HOUSEFACILITY NUMBER:
434415603
ADMINISTRATOR/
DIRECTOR:		JO-ANN PANGANFACILITY TYPE:
850
ADDRESS:16035 LOS GATOS ALMADEN ROADTELEPHONE:
(408) 356-3211
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY: 43TOTAL ENROLLED CHILDREN: 43CENSUS: 20DATE:
02/05/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jo-Ann PanganTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Director Jo-Ann Pangan, for an unannounced Annual/Random inspection. LPA was granted access to the facility by the Director and toured both indoors and outdoors during the inspection. Upon arrival, there were 20 children (preschool) and # 5 staff (2 Teachers/ 2 Aides/ 1 Director) present, which is compliant with the facility license capacity and ratio requirements. LPA observed all required postings near the entrance to the facility. Hours of operation for the facility are Monday – Friday, 07:00AM-05:00PM. There are no active waivers or exceptions.

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. All staff persons present had a criminal record clearance or exception.

LPA reviewed sign-in/out sheets, facility roster (LIC9040), and fire/disaster drill log during today’s inspection. Sign-in/out was observed to be completed with full legal signature and time of day. The last fire/disaster drill was conducted on 01/23/2025, which is compliant with the six month requirement for facilities. LPA observed a fully charged 3A40BC fire extinguisher last serviced 04/24/2024, which is compliant with state fire marshal regulations. LPA observed a fully functioning smoke detector system and a working carbon monoxide detector. Director states that she does have children in care who require Incidental Medical Services. LPA observed the medication is properly stored out of reach of children, in a locked box. LPA observed one EPI pen not in original packaging but had the child's name written in black marker and was in a separate bag with instructions from Kaiser Permanente along with Parent's permission and instructions.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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 02/05/2025 12:55 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 02/05/2025 at 11:41 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: PEPPERTREE SCHOOLS COTTAGE HOUSE
FACILITY NUMBER: 434415603

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101226(e)(1)(B)
Health-Related Services
(e) In centers where the licensee chooses to handle medications: (1) All prescription and nonprescription medications shall be centrally stored in accordance with the requirements specified below: (B) Each container shall have an unaltered label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not have EPI pen in original packaging this does not comply with the section cited above in 1 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Director to release the EPI pen back to the parents at pick up. Director will not accept the medication unless it is in the original packaging or has the manufacturer's directions with the EPI-pen to insure that instructions for administrating are complete and an expiration date was accessible. Director will email LPA with the progress of this situation.
Type B
Section Cited
CCR
101238.2(d)(2)
Outdoor Activity Space
(d) The surface of the outdoor activity space shall be maintained: (2) Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above due to a hole on the outdoor area that was covered by astro-turf, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Director will have maintenance fill in the hole to level out the ground and send LPA a video showing that it is no longer a risk to children in care.
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:Joel Segura
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


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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: PEPPERTREE SCHOOLS COTTAGE HOUSE
FACILITY NUMBER: 434415603
VISIT DATE: 02/05/2025
NARRATIVE
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records.
For IMS information see PIN 22-02-CCP. 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/.

Indoor areas of the facility were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom, not utilized by the children, which can be used to isolate a sick child, if necessary. The Facility has a working telephone which is a land line. Cleaning and maintenance for the facility is conducted by an outside service and is completed in the evenings after all day care children have left the premises. The Director states that there are no weapons or firearms on the premises.

The outdoor area of the facility was inspected and observed to be fenced in. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (astro-turf) to absorb falls. No outdoor bodies of water were observed during today’s inspection. LPA observed a hole larger than a foot wide that was not visible as it was under the astro-turf. This was located near the large tree at the back of the play yard near the off-limits areas. Shaded rest area is provided by large trees.

This facility offers transportation from the local school for their TK clients. LPA inspected the van used for transportation. All safety lights were working, seat belts were visible and car seats were in place. Director has a valid driver's license on file.

Food is provided by the facility and is stored, prepared, and served in a safe and healthful manner to the children. Facility offers an AM/PM snack to children. Water is filtered and bottles come from home with child's name. If they forget their bottles a cup would be provided.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
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: PEPPERTREE SCHOOLS COTTAGE HOUSE
FACILITY NUMBER: 434415603
VISIT DATE: 02/05/2025
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10 children’s files (preschoolers) were reviewed during today’s inspection for the following records: Physician’s Report (LIC701), Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Signed Admission Agreement, and Immunization Records (PM286). LPA observed records to be complete except for two children were missing a Health History/Parent's Report.

5 staff files (1 / Director/ 2 Teachers / 2 Aides) were reviewed for the following records: Transcripts/Verification of Experience, Health Screening Report (LIC503), Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, Tuberculosis (TB) Clearance, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). There is at least one staff member present with current CPR/First-Aid that expires 01/06/2026. The Director has current Mandated Reporter Training that expires on 08/27/2026. LPA reminded the Director that the Mandated Reporter Training must be renewed by all staff every 2 years and meet the requirement of AB1207.

The Director understands that the site director shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. LPA reminded Director Pangan 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, such as field trips.

LPA Collected the following documents during today's inspection:
  • Lead Testing Results dated 04/03/2023
  • Current LIC9040 - Facility Roster

Due to today's inspection, 2 - Type B Deficiencies were cited, more details provided on the attached LIC809-D. Exit interview conducted with Director Jo-Ann Pangan, report provided and reviewed along with appeal rights. NOTICE OF SITE VISIT WAS PROVIDED 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: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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