<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444416436
Report Date: 07/15/2021
Date Signed: 07/15/2021 04:41:42 PM

Document Has Been Signed on 07/15/2021 04:41 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:L'ACADEMY PRESCHOOL SANTA CRUZFACILITY NUMBER:
444416436
ADMINISTRATOR:KATRINA DUKEFACILITY TYPE:
830
ADDRESS:3205 SALISBURY DRIVETELEPHONE:
(415) 361-1879
CITY:SANTA CRUZSTATE: CAZIP CODE:
95065
CAPACITY: 13TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
07/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Nolan, KarenTIME COMPLETED:
05:00 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 Analyst (LPA), Goodell met with director Karen Nolan for an unannounced Annual Inspection. The facility’s hours of operation are Monday-Friday, 7:30am-5:30pm. LPA arrived during naptime and conducted a census of three children present with one staff.

LPA toured all activity/classroom areas, children’s furniture, equipment, food service area, outdoor area and restrooms. LPA observed the sign/in-sign/out is obtained through 1core App. Facility provides breakfast, morning/afternoon snack and lunch. LPA observed a current menu and activity posted. LPA observed cleaning compounds are stored inaccessible to children. LPA observed the changing table meets Title 22 requirements and located near a sink. LPA observed fire extinguisher 2A10BC, dual smoke and carbon monoxide detector. LPA observed fire drill log and children roster maintained.

LPA reviewed children files. Documents included Identification and Emergency Information (LIC700), Child’s Preadmission Health History (LIC702), Child’s Preadmission Health Evaluation (LIC701), Consent for Medical Treatment (LIC627), Notification of Parent’s Rights (LIC 995), Personal Rights (LIC613A). LPA observed Infant’s Needs and Services plan, Toilet-training plan, and Infant feeding plan was not on file for child #1 and #2 which poses a potential risk to children in care. Director acknowledged that infant needs and services plan shall be included in the infant’s file. Director stated proof will be submitted to LPA by 7/29/2021.
Report Continues on LIC-809C
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kristal Goodell
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2021
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 3
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: L'ACADEMY PRESCHOOL SANTA CRUZ
FACILITY NUMBER: 444416436
VISIT DATE: 07/15/2021
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
26
27
28
29
30
31
32
LPA observed that all infant bottles are labeled and dated. Director stated all milk and food are returned daily. LPA observed nap equipment.

LPA reviewed staff files and educational requirements, including the Infant course. Documents included Health Screening Report (LIC503), TB Clearance, Personal Record (LIC501), Criminal Record Statement (LIC508), Notice of Employee Rights, Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC9108) and certificate for Mandated Reporter Training. LPA observed that at least one staff member present during today’s inspection has current Pediatric CPR/First Aid that expires on 6/12/2023.

LPA provided a copy of the Effects of Lead Exposure brochure. LPA discussed with the Director Assembly Bill 2370, which will require licensed Child Care Facilities to test their water for excessive amounts of lead. Testing will be required from January 1st, 2020 to January 1st, 2023 and must be conducted every five years from the initial testing.

LPA provided the Community Care Licensing website www.ccld.ca.gov, so the director can obtain updated licensing information, new regulations, self-assessment guides and access forms. LPA advised the director of their responsibility to stay current in regards to new regulations.

Title 22 deficiency cited. LPA reviewed report with the director and provided copies. Notice of Site Visit issued and must remain posted for 30 days. Appeal Rights also issued and discussed.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kristal Goodell
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/15/2021 04:41 PM - It Cannot Be Edited


Created By: Kristal Goodell On 07/15/2021 at 03:02 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: L'ACADEMY PRESCHOOL SANTA CRUZ
FACILITY NUMBER: 444416436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2021
Section Cited
CCR
101419.2(d)

1
2
3
4
5
6
7
Infant Needs and Services Plan.The needs and services plan shall be included in the infant’s file. This requirement is not met due to during file review Infant’s Needs and Services plan, Toilet-training plan, and Infant feeding plan was not on file for child #1 and #2 which poses a potential risk to children in care.
1
2
3
4
5
6
7
Director acknowledged requirement and stated proof will be submitted to LPA by 7/29/21

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Kristal Goodell
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3