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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417019
Report Date: 11/22/2021
Date Signed: 11/22/2021 12:46:27 PM

Document Has Been Signed on 11/22/2021 12:46 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:AGNEW DISTRICT PRESCHOOLFACILITY NUMBER:
434417019
ADMINISTRATOR:ANGELA GOMEZFACILITY TYPE:
850
ADDRESS:3534 ZANKER ROADTELEPHONE:
(408) 423-3671
CITY:SAN JOSESTATE: CAZIP CODE:
95134
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 6DATE:
11/22/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Anita KinneyTIME COMPLETED:
12:55 PM
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Licensing Program Analysts (LPAs) Dung Mac and Marilou Monico, conducted an announced pre-licensing inspection to the Facility today. LPAs met with Anita Kinney, Program Specialist, and Angela Gomez, Site Director, and explained the nature of today's inspection. LPAs observed six children in Room D105 and two staff members. Anita states that the six children and the two staff belong to the Special Academic Instruction (inclusion program) under the Education Department.

The Facility is located on the premises of Agnew Elementary School. The Preschool Program will operate Monday through Friday 7:00AM-6:00PM, serving Preschool children ages 3-5 years old in Rooms D103 and D105.

A fire clearance approval was received prior to today's inspection. LPAs toured and measured the indoor and outdoor areas of the Facility during today's inspection.

INDOOR MEASUREMENTS ARE AS FOLLOWS:

Room D103 = (33.583 x 35.833) minus (encumbered) (8.583 x 16.500 + 1.833 x 8.000)
= 1,203.379 - 156.283 = 1,047.096 sq.ft

Room D105 = (33.583 x 35.583) minus (encumbered) (17.583 x 8.667 + 1.750 x 6.833)
= 1,194.983 - 164.348 = 1,030.635 sq.ft

TOTAL INDOOR SPACE = 2077.731 sq. ft divided by 35 sq. ft. = 59 children

The preschool has 58 cubbies, 8 tables, 65 chairs, 16 mats, and 24 hooks. Anita states that more than 50 percent of the children will be attending on a part-time basis and will not be napping at the center.

Report To Be Continued on Page #2
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Dung Mac
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AGNEW DISTRICT PRESCHOOL
FACILITY NUMBER: 434417019
VISIT DATE: 11/22/2021
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There are adequate equipment, supplies and toys for children. Children will bring their own bottle of water and there is water filter station located in the hallway outside of Room D103. Transportation will not be provided by the Facility.

Facility has 8 sinks (120) and 4 toilets (60) available for preschool children to use. The sinks used by children only have cold running water. There are 2 separate staff bathrooms. One of the staff bathrooms will be utilized by sick children if necessary. Sick children will be isolated in the director's office (next to the reception area) and isolation equipment will be provided.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A Plan of Operation that includes IMS must be submitted to the Department. 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

Medications will be stored in the director's office. First Aid supplies will be stored on high shelf in each classroom inaccessible to children. Cleaning supplies will be stored in a locked janitor's closet located in the hallway outside Room D103. LPAs observed a solid waste container with a tight-fitting lid and smoke/carbon monoxide detectors in each classroom. LPAs did not observe any fireplaces or wall heaters at the Facility. The Facility has central heating/air conditioning in both classrooms. Both preschool classrooms have appropriate lighting. Anita states that there are no firearms on the premises.

The facility has food preparation area (kitchen) located close to the reception area and is functional, has hot and cold running water, sink, refrigerator, microwave, stove, and storage space for food. Facility will serve breakfast and afternoon snacks. Anita states that for School Year 2021-2022, breakfast and afternoon snacks will be prepared at the cafeteria of Agnew Elementary School. Children will bring their own lunch. Disposable utensils and plates will be utilized by the Facility.


Report To Be Continued on Page #3
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Dung Mac
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AGNEW DISTRICT PRESCHOOL
FACILITY NUMBER: 434417019
VISIT DATE: 11/22/2021
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During the inspection, Anita mentioned that the preschool program will be combined with the Special Academic Instruction (inclusion program) once the preschool is licensed.

OUTDOOR MEASUREMENTS:
(107.750 x 60.333) - (9.833 x 13.333) (encumbered)
= 6,500.880 - 131.103 = 6,369.777

TOTAL OUTDOOR SPACE = 6,369.777 divided by 75 = 84 children

The Playground will be utilized by the Preschool program and inclusion program. The playground is surrounded by appropriate fencing. LPAs observed a storage and is off limits to children. The areas around and under the play structure are cushioned with material (rubber foam) that absorbs falls. Shade is provided by canopies and outdoor patios. There are adequate equipment and toys for children outdoors. Drinking water will be provided outdoors via individual water bottles and water filter station. There were no bodies of water observed.

Site Director, Angela, has met the education and experience qualification requirements and her Pediatric First Aid/CPR Certifications expire July 22, 2023. Site Director has proof of immunity against Measles and Pertussis, Influenza on file.

Fingerprint clearances for individuals at this facility who require caregiver background checks are issued by the State Department of Education and/or County Office of Education and do not come under the jurisdiction of Community Care Licensing division.

LPAs conducted an exit Interview and advised Anita that a license for 48 Preschool children will be submitted to Licensing Management for the final stage of approval upon receiving of the following items:
1) Applicant will submit a plan on how the Agnew District Preschool and Special Academic Instruction (inclusion program) will maintain ratio, capacity, and supervision during indoor and outdoor inclusion activities.

Report To Be Continued on Page #4
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Dung Mac
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AGNEW DISTRICT PRESCHOOL
FACILITY NUMBER: 434417019
VISIT DATE: 11/22/2021
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2) Health Preventative Training including Nutrition and Lead Prevention Training of at least one staff member who will working at the facility.
3) Immunization in Measles, Pertussis, and Influenza, TB test, and Statement Acknowledging Requirement to Report Child Abuse (LIC 9108) for Applicant Representative, Nancy Morin.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Dung Mac
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4