434417019-4-14-2023-07-CC-MSMS-CQVUB7-20230414152553

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417019
Report Date: 04/14/2023
Date Signed: 04/14/2023 03:25:59 PM

Document Has Been Signed on 04/14/2023 03:25 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 PRESCHOOL		FACILITY NUMBER:	434417019
ADMINISTRATOR:	ANGELA GOMEZ		FACILITY TYPE:	850
ADDRESS:	3534 ZANKER ROAD		TELEPHONE:	(669) 369-4185
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95134
CAPACITY: 48	TOTAL ENROLLED CHILDREN: 48	CENSUS: 11	DATE:	04/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Natacha Costa		TIME COMPLETED:	03:45 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	Licensing Program Analysts (LPAs) Mel Matos and Farida Raja met with Natacha Costa, Director, for an unannounced Required - 1 Year inspection. LPAs toured the indoor and outdoor areas of the Facility during today's inspection. LPAs observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menu, Activity Schedule, and Waiver (lack of outdoor space). Days and hours of operation are Monday through Friday 7:30 am to 5:30 pm. The Facility is licensed to serve a maximum of forty eight (48) children ages 3-5 years in Rooms D103 & D105. Note: Facility is located on the campus of Agnew Elementary School. The Facility has no active waivers on file. LPAs reviewed five children's and three staff files (1 director and 2 teachers) during today's inspection. Each child's file reviewed contains the required documents; including the Information and Emergency Information form (LIC 700) and immunization records. All staff files reviewed contain the required documents; including transcripts/verification of experience/immunization records, and Health Screening Report. All staff have current certificates of completion of the Mandated Reporter Training for Child Care Workers on file. Last fire/disaster drill was completed on March 25, 2023. Natacha and staff has current CPR and First Aid certifications on file. Natacha 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). LPAs observed that the teacher/child ratio was in compliance during today's inspection. LPAs observed 11 napping children with one teacher in Room D103 during today's inspection. Natacha understands the conditions, limitations, and capacity specifications of the Facility license. Natacha understands that children shall be visually supervised at all times. Any child(ren) who exhibit symptoms of illness including, but not limited to, fever or vomiting, are not accepted in care. Any child(ren) who become ill during the day, shall be isolated in the director’s office area. LPAs observed that the Facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. The Facility has adequate ventilation, including central air conditioning/heating. Natacha states that the school districts provides janitorial services for Facility Monday through Friday in the evenings. Natacha understand that the Facility must be kept free of flies and other insects & rodents. LPAs observed that all furniture and equipment is in good condition and safe for the children.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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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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: 04/14/2023

NARRATIVE

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Drinking water is readily available for the children in the Facility (indoor/outdoor) via water filter refill stations/reusable water bottles. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Natacha states that there are no weapons or firearms on the premises. The Facility has functioning carbon monoxide detectors in the Facility.

The food preparation and storage areas, located down the hall from the classrooms, are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. The Facility provides breakfast, lunch, and PM snacks to the children. The Facility has trash cans with tight fitting lids for solid waste. Cleaning supplies are inaccessible to the children and stored in high cabinets and janitor's closet inaccessible to children. Natacha states that there are no poisons in the Facility. LPAs observed a complete First Aid kit in the Facility. Natacha states that the Facility does not administer any medications at this time. Natacha understands that smoking is not allowed on the Facility premises.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated 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

The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPAs observed that the outdoor equipment is age appropriate and in good condition. There is a secure play structure that is age appropriate for the preschool children. There is sufficient cushioning materials (rubber surfacing) under and surrounding the play structure. Shade is provided by building overhangs and sun shades. LPAs did not observe any bodies of water. Natacha states that the Facility does not provide transportation.

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.

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.

Exit interview conducted and report was reviewed with the Director, Natacha Costa. Natacha agreed to submit additional documents re: director paperwork to LPA Matos by Friday April 28, 2023.
A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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