Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701596
Report Date: 10/19/2017
Date Signed 10/19/2017 12:24:22 PM

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:CAMPBELL PARENTS PARTICIPATION PRESCHOOLFACILITY NUMBER:
430701596
ADMINISTRATOR:MONICA GRODINFACILITY TYPE:
850
ADDRESS:528 HARRISON STREETTELEPHONE:
(408) 866-7223
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:26CENSUS: 11DATE:
10/19/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Sherrie RoseTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Rangel made an attempted case management inspection to the facility on 10/12/17 at 1:00pm. LPA returned on 10/19/17 to complete the case management inspection for unusual incident reports received on 10/10/17 and 10/12/17 and to conduct an annual random inspection.

A portion of this inspection was made to amend a report dated 9/13/17. The purpose for amending the report is that penalties issued were in the incorrect amount.

LPA met with director Sherrie Maleson and explained the nature of today's inspection to her. LPA toured the Facility both inside and outside during today's inspection. LPA 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), snack Menus, and Activity Schedule.

A review of staff records on indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

LPA reviewed five children's and two staff files during today's inspection. Each child's file reviewed contains the Information and Emergency Information form (LIC 700). The staff files reviewed contains the required transcripts/verification of experience. Director has current CPR and First Aid certifications on file. Director 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).

LPA observed that the teacher/child ratio was in compliance during today's inspection. There were 11 parent's working with the children at the school today. Director understands the conditions, limitations, and capacity specifications of the Facility license. Director understands that children shall be visually supervised at all times.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 205-9167
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2017
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: CAMPBELL PARENTS PARTICIPATION PRESCHOOL
FACILITY NUMBER: 430701596
VISIT DATE: 10/19/2017
NARRATIVE
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Report continued from previous page:
Solid waste containers with tight-fitting lids are throughout the Facility. Children's bathroom is clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Director states that there are no weapons or firearms on the premises.

The food preparation and storage areas are clean. The kids do not have lunch but they have snack, the school is operating a half day program. All food and beverages that require refrigeration are stored in covered containers. Cleaning supplies are stored on high shelves, away from children. Medication(s) at the Facility will stored on high shelves in the kitchen away from the children. LPA observed all furniture, rooms and equipment are in good condition and safe for the children. The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. Drinking water is readily available for the children in the Facility via water cooler and disposable cups and in the outdoor playground area via pitchers and disposable cups. LPA observed that the outdoor equipment is age appropriate and in good condition. There is sufficient resilient materials in the outdoor playground area. LPA did not observe any bodies of water.

LPA discussed Zero Tolerance with $500 civil penalty and the requirements of AB633 to director and provided her with the AB633 fact sheet. Parent Notification Requirements (AB 633) must be followed, and the parent or authorized representative of every child in care shall be given a copy of today's report and a signed LIC 9224 must be kept in each child's file. For the next 12 months, the parent or authorized representative of any newly enrolled child must also be given a copy of today's report, and a signed LIC 9224 must be kept in their child's file as well.

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 following page contains the violation being cited according to Title 22 Regulations. In regards to the Lack of Supervision violation, you are hereby notified that an immediate $1000.00 civil penalty per violation is being assessed because this is a repeat violation within a 12 month period.



Appeal rights printed and reviewed.
A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 205-9167
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2017
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: CAMPBELL PARENTS PARTICIPATION PRESCHOOL
FACILITY NUMBER: 430701596
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2017
Section Cited
CCR
101229(a)(1)
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Care and Supervision. No child shall be left without the supervision, including visual observation, of a teacher at any time. On two seperate incidents, a child entered and used the bathroom.
Parent Notification Requirements (AB 633) must be followed, and the parent or authorized representative of every child in care shall be
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The licensee must ensure all children in care are visually observed at all times. Director stated that she will write a plan of correction which must be submitted within 24 hours. Director has changed the job descriptions and emailed all staff and parents regarding supervision. Copies of the email and job descriptions will be submitted to CCL. This
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given a copy of today's report and a signed LIC 9224 must be kept in each child's file. For the next 12 months, the parent or authorized representative of any newly enrolled child must also be given a copy of today's report, and a signed LIC 9224 must be kept in their child's file as well.
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is a Zero Tolerance violation & licensee is being charged a civil penalty in the amount of $1000.00. Licensee is required to attend an informal meeting at the Community Care Licensing San Jose Regional Office. The date and time of that meeting will be sent to the licensee at a later date.



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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: Timetra FaulconTELEPHONE: (408) 205-9167
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2017
LIC809 (FAS) - (06/04)
Page: 4 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: CAMPBELL PARENTS PARTICIPATION PRESCHOOL
FACILITY NUMBER: 430701596
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2017
Section Cited
CCR
101229.1(a)(1)
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The person who signs the child in/out shall use their full legal signature and shall record the time of day. LPA observed that there were some children who did not have parents signing them out of attendance.
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Director stated that reminders to parents regarding sign in/out procedures will be given verbally and in an email.

Plan of correction will be placed in writting and sent to CCL by 11/02/17.
Type B
11/02/2017
Section Cited
HSC
1596.7995
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SB 792 Immunization Requirement. A person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption. During today’s inspection, LPA observed one staff member and 2 parent volunteers cannot show proof of immunizations
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Director stated she will forward staff copies of immunization record for measles, pertussis, and influenza and copies of infuenza immunization or declination for volunteers to LPA by 11/02/17.
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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: Timetra FaulconTELEPHONE: (408) 205-9167
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2017
LIC809 (FAS) - (06/04)
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