FACILITY VISIT CHECKLIST CHILD CARE CENTERS AND INFANT … · FACILITY VISIT CHECKLIST CHILD CARE...

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY .__) -..___/ CALIFORNIA DEPARTMENT OF SOCIAL SERVICES FACILITY VISIT CHECKLIST CHILD CARE CENTERS AND INFANT CENTERS Review facility file prior to visit. Check to see that the following information has been updated , if required , and con t ained in the file. Indicate the date the informatio was submitted to the licensing agency in the space provided for each item \ {?_ requested . I TE .. Lf-5 Ll-4 OOt LICENSE ANNIVERSARY DATE ON FILE REQUESTED RECEIVED ' App li cation Information (LIC 215) j L Criminal Record Clearance and Child Abuse Index Checks (LIC 198) (updated for current staff subject to fingerprint requirements) I I -- Licensee Affidavit Regarding Persons Exempt From Fingerprint Requirements (if not on LIC 500) - --r·----········ Administrative Organization (LI C 309)* I .. -r-------- Estimated Monthly Operating Budget (LIC 401 ). Budget Information (LIC 420 ), Financial _____ §_!_?!teme0t and Information (LIC 403, LIC 404) --1----------·- ·-· Articles of Incorporation, Constitution and Bylaws (if applicable) - Partnership Agreement (if applicab le ) -·---- Designation of Administrative Responsibility (LIC 308)* "- t)./L7 /c 9/_f/i Personnel Report (LIC 500) Updated* - --- I Facility Floor/Plot Plan (LIC 999) Verification of Qualifications of Facility Di rector I Emergency Disaster Plan (LIC 61 0) Ir/6 7 Disaster and Fire Drills (every 6 months) I I Plan of Operation Adm issions Po li cies and Procedures/Fee Sched ule Hea lth Screening Re port- Facility Personnel (LIC 503) I Daily Activity Schedule Fire Clearance (consistent with terms and limitations of license) / I Bacteriological Analysis of Private Water Supply (if applicable) I ----····--· License Fee Received I 1-S )- -.;, \, oL\) ···---· . NOTES AND COMMENTS /. I / ' : LicVnse Emer Pa r ents 'vR i hts Poster Ri v . . • L. C :-::; L Pos tin enc Plan Earth uake hts Menus , Act1v1t 1st, ar seat aw g g y q g g y Waiver? Sign In/Out? In door : Heating/LightingNentilat ion ? Drink ing Wa ter? To xic Materials? Bathroom s (working/c lean)? \ '1--C Mats/Cots ( good condition )? L{ 1 stAid Kit? -tcr c.- k Isolation of Sick Children? Outdoor: Fenced? Play equipment? Infant: Changing Table ? Needs & Services Plan ? Bottles/Food Stored & Labe led Correct ly? Care & Supervision? Medication? tJ Food P re/ Plan/Dishes? Sol id Wasted Containers? Bodies of Wa ter? Su fficie nt Res ilient? Da ily Log ( diaper change, _______ _ LIC 9118 (11103) *Other verifying documents may be substituted for these LIC forms D

Transcript of FACILITY VISIT CHECKLIST CHILD CARE CENTERS AND INFANT … · FACILITY VISIT CHECKLIST CHILD CARE...

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY .__) -..___/ CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

FACILITY VISIT CHECKLIST CHILD CARE CENTERS AND INFANT CENTERS

Review facility file prior to visit. Check to see that the following information has been updated , if required , and contained in the file. Indicate the date the informatio was submitted to the licensing agency in the space provided for each item

\ {?_ requested . I DATE--~----0-A TE ..

Lf-5 Ll-4 OOt q~ LICENSE ANNIVERSARY DATE ON FILE REQUESTED RECEIVED ' Application Information (LIC 215) j L Criminal Record Clearance and Child Abuse Index Checks (LIC 198) (updated for current staff subject to fingerprint requ irements) I I

-- ~-----Licensee Affidavit Regarding Persons Exempt From Fingerprint Requirements (if not on LIC 500) - --r·----········ Administrative Organization (LIC 309)* I

.. -r--------Estimated Monthly Operating Budget (LIC 401 ). Budget Information (LIC 420), Financial _____ §_!_?!teme0t and Information (LIC 403, LIC 404) --1----------·- ·-·

Articles of Incorporation, Constitution and Bylaws (if applicable ) -

Partnersh ip Agreement (if applicable) -·----

Designation of Administrative Responsibility (LIC 308)*

"- t)./L7 /c 9/_f/i Personnel Report (LIC 500) Updated* ----I

Facility Floor/Plot Plan (LIC 999)

Verification of Qualifications of Facility Director I Emergency Disaster Plan (LIC 61 0) Ir/6 7 Disaster and Fire Drills (every 6 months) I

I

Plan of Operation

Adm iss ions Policies and Procedures/Fee Sched ule

Health Screening Report- Facility Personnel (LIC 503) I

Daily Activity Schedule

Fire Clearance (consistent with terms and limitations of license) / I Bacteriolog ical Analysis of Private Water Supply (if applicable) ~ I

----····--·

License Fee Received I 1-S)- -.;,\, oL\)

···---· . NOTES AND COMMENTS / . I /

' : LicVnse Emer Parents'vRi hts Poster Person~l Ri

v . . • L. C :-::; L Postin enc Plan Earth uake hts Menus, Act1v1t 1st, ar seat aw g g y q g g y

Waiver? S ign In/Out?

Indoor: Heating/LightingNentilation? Drinking Water? Tox ic Materials?

Bathrooms(working/c lean)? \ '1--C V~ Mats/Cots(good condit ion)? L{

1 stAid Kit? -tcr c.-k ~~ Isolation of Sick Children?

Outdoor: Fenced?

Play equipment?

Infant: Changing Table? Needs & Services Plan?

Bottles/Food Stored & Labeled Correctly?

Care & Supervision?

Medication? tJ Food Pre/Plan/Dishes?

Sol id Wasted Containers?

Bodies of Water?

Sufficient Res ilient?

Daily Log (diaper change, feedin~l? _______ _

LIC 9118 (11103) *Other verifying documents may be substituted for these LIC forms

D

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STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

FACILITY NAME: TAMIEN CHILD CARE CENTER ADMINISTRATOR: OSTROWSKI, MARY ADDRESS: 1197 LICK AVENUE CITY: SAN JOSE CAPACITY: 84 TYPE OF VISIT: Annual/Random MET WITH: Marjorie Hawkins & Erin Subala

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131

STATE:CA CENSUS: 10 UNANNOUNCED

FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED:

434400195 850

(408) 271-1980 95110

12/27/2010 08:50AM 12:30 PM

NARRATIVE 1 LPA Shan Tan met with Site Supervisor Marjorie Hawkins and Director Assistant Erin Subala for an 2 unannounced annual random visit today. The center runs from 6:30am to 6:30pm Monday to Friday. LPA 3 toured all the classrooms and play yards for health and safety inspection. LPA observed 3 staff members with 4 5 children in Transition Room 1, 2 staff members with 3 children in Preschool Room 2 and 1 staff member 5 with 2 children in Pre-K Room. Facility met teacher/ch ild ratio today. Drinking water is provided by water 6 fountains in each classroom and outside. Water jugs are also avai lable for children when outside water 7 fountains are not turned on . Children and staff bathrooms are clean. Paper products are available. Variety of 8 age appropriate books and art materials for children are available in the classrooms. All furniture and 9 equipment are age appropriate as well. Toxins and harmful objects are kept inaccessible to ch ildren. No 10 medication is administered in the program today. First Aid kits were available in each classroom and the 11 office. The play yards are completely fenced. Sands are used as cushion ing under the play structure. Trees 12 and overhang building provide shade. Facil ity has posted Licensing required posting including license, 13 Emergency Plan , Parents Rights Poster, Personal Rights, Menus Activity List and Car Seat Law. Last fire 14 drills-practiced is done on 3/10/10. LPA verified facility staff fi les completed and reviewed a sample of 15 chi ldren's fi les . 2 staff passports have been completed. A review of staff records during today's visit 16 indicates that all staff or other individuals who require caregiver background checks have received 17 criminal record and child abuse index clearances or exemptions. 18 The following was discussed: Isolation of sick chi ldren; supervision of ch ildren; teacher-child ratio; 19 requirements for reporting suspected child abuse ; unusual incident/injuries; chi ldren's personal rights and no 20 corpora l punishment. LPA also reminded of the applicable Civil Penalty per person for those adults who have 21 not received fingerprint clearances, are not associated to the license, come into contact with and or provide 22 care and those who provide supervision to the children. Forms and Title 22 Regulations can be obtained 23 through the internet at www.ccld.ca.gov. A copy of child care parents notification Assembly Bill 633 and 24 Acknowledgement of Receipt of Licensing Reports (LIC 9224) form were provided and explained. 25 Facility was in compliance druing today's visit, no deficiency was cited .

During today's visit, an updated Facility Persnnel (LIC 500) form was requested to be submitted to the licensing office by 1/3/11. Notice of Site Visit was issued and must be posted within 30 consecutive days.

SUPERVISOR'S NAME: Sandy Knight

LICENSING EVALUATOR NAME: Shan Tan

LICENSING EVALUATOR SIGNATURE:

~

TELEPHONE: (408) 324-2148

TELEPHONE: (408) 334-8321

DATE: 12/27/2010

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

FACILITY REPRESENTATIVE SIGNATURE:

~~ DATE: 12/27/2010

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 1

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

FACILITY VISIT CHECKLIST CHILD CARE CENTERS AND INFANT CENTERS

Review facil ity file prior to visit Check to see that the following information has been updated , if requ ired , and contained in the file. lndic~he date the inJqrma~iO f)J wAs submitteA to th~ licensing agency in the space provided for each item requested . IOAA/li'.Q..vr._ ()~ l cf ( 10f__Q__ ~iJJ,

Application Information (LIC 215) L Criminal Record Clearance and Child Abuse Index Checks (LIC 198) (updated for current staff subject to fingerprint requirements)

------'---~_,_ __ .:.__ __ _,_ __________________ 1------+------f-----·- --·--Licensee Affidavit Regarding Persons Exempt From Fingerprint Requirements (if not on LIC 500)

..... ----------'-----------------------------+------+-----i------------Adm inistrative Organization (LIC 309)* ~ ------ -------'--'--------1-----____.__ __ -- - ______ , __ Estimated Monthly Operating Budget (LIC 401 ). Budget Information (L IC 420), Financial

---~_?tement and Information (L IC 403, LI C 404) ------+-------+----------+-----................. ..

-------~-rt~ic~l-e_s ___ o_~ _ln-c-or_p_o-ra-t-io_n_. -C-o-ns-t-itu-t-io_n_a_n_d_B_y_la_w_s- (if_a_p_p-li-ca_b_l_e_) -----.,. ....... --.--lr------+----=t=···----· Partnership Agreement (if applicable) _

Designation of Administrative Responsibility (LIC 308)* {-'/If~~ 1}\,b i /

Personnel Report (LIC 500) Updated* 1/ -·------'----'--------'----'----------------------+----\.o<~--+---------r--------

Facility Floor/Plot Plan (LIC 999)

Verification of Qualifications of Facil ity Director

Emergency Disaster Plan (LIC 610)

~~· _D_i_sa_s_t_er_a_n_d_F_ire_D_ri_lls_(e_v_e_~_6_m_o_n_th_s_) __________________ ~-v---~----~~-----Pian of Operation

Admissions Policies and Procedures/Fee Schedule

Health Screening Report- Facility Personnel (LIC 503)

,l0 Dai ly Activity Schedule

Fire Clearance (consistent with terms and limitations of license) \/ I ------------------------'-----------f----I..L------::J:,------i-------·-

Bacteriolog ica l Analysis of Private Water Supply (if applicable) ~ I ·-·--·-----------------------'-----------+=--"":...___--TJ--t-;,---~.----:=:-=---:---------------

License Fee Received GtA£cl!_if 1flg5d?. o--o __ _ NOTES AND COMMENTS

Posting : License , Emergency Plan , Earthquake, Parents' Rights Poster, Personal Rights , Menus, Activity List, Car seat Law

Waiver? Sign In/Out?

Indoor: Heating/LightingNentilation? Drinking Water? Toxic Materials?

_§athrooms(working/clean)?

1st Aid Kit?

Kitchen (w/hot & cold water)?

Enough Food ,{date cu rrent)?

Outdoor: Fenced?

Play equipment?

Infant: Changing Table?

Toys/Carpet( clean)?

Isolation of S ick Children?

Needs & Services Plan?

Mats/Cots(good condit ion)?

Medication?

Food Pre/Plan/Dishes?

Solid Wasted Containers?

Bodies of Wate r?

Sufficient Resi lient?

Daily Log(diaper change, feeding )?

_§_9tti~~-F_o~d Stored & Labeled Cor_re_c_t l~y_? __________________________ _

Care & Supervision? ···-~·- --·· .. -- .

LIC 91 18 (11/03) *Other verifying documents may be substituted fo r these LIC forms

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STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

FACILITY EVALUATION REPORT(Cont) CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131

FACILITY NAME: TAMIEN CHILD CARE CENTER FACILITY NUMBER: 434400195

VISIT DATE: 11/09/2011

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NARRATIVE

Facility evaluation report is continued from the previous page:

LPA observed that all rooms are clean and safe for all children and staff. Director states that the Facility has a third-party cleaning service that cleans the Facility Monday through Friday in the evenings. Drinking water is readily available for the children in each room and in the outdoor playground areas via pitchers and paper cups. 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. Director states that there are no weapons on the premises. The school provides snacks. Children can bring their own lunch or the school orders food from outside for the children. Cleaning supplies are inaccessible to the children. Any medications at the Facility are stored appropriately in the upper cabinet in each classroom. LPA observed all furniture and equipment is in good condition and safe for the children . The playground areas utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition . There is also sufficient sands and poured rubber foam as resilient materials in the outdoor playground area . LPA did not observe any bodies of water.

LPA discussed Zero Tolerance with $150 civil penalty and the requirements of AB 633 with the director and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and she understands the requirements. Licensing Forms, Title 22 Regulations and information can be obtained through the internet at www .cdss.ca.gov. LPA conducted an exit interview with Director prior to the conclusion of today's visit.

As a result of today's visit, no deficiency was cited.

NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight TELEPHONE: (408) 324-2148

TELEPHONE: (408) 334-8321 LICENSING EVALUATOR NAME: Shan Tan

LICENSING EVALUATOR SIGNATURE:

DATE: 11 /09/2011

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2011

LIC809 (FAS) • (06/04) Page: 2 of 2

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

FACILITY EVALUATION REPORT CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131

FACILITY NAME: TAMIEN CHILD CARE CENTER ADMINISTRATOR: OSTROWSKI , MARY

FACILITY NUMBER: FACILITY TYPE:

434400195 850

(408) 271-1980 95110

11/09/2011 08:50AM 01 :30PM

ADDRESS: 1197 LICK AVENUE TELEPHONE: CITY: SAN JOSE STATE:CA

CENSUS: 31 UNANNOUNCED

ZIP CODE: CAPACITY: 84 DATE: TYPE OF VISIT: Annual/Random TIME BEGAN: MET WITH: Erin Subala TIME COMPLETED:

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NARRATIVE Licensing Program Analyst (LPA), Shan Tan, conducted an unannounced random visit to the Facility today. LPA met with director Erin Subala and explained the nature of today's visit to her. LPA toured the Facility both inside and outside during today's visit. 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), Menus and Activity Schedule. The Facility has no acti11e waivers/exceptions and the Facility has had no prior deficiencies within the past 12 months. A review of staff records on 11/01/11 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 also reminded Subala of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violations within a 12 month period. LPA observed the medical assessment and the Information and Emergency Information form {LIC 700) in 10 children 's files. LPA observed the required health screening in 3 staff files. 2 teacher's passports have been completed today. Director has current CPR and First Aid certifications on file which expire on 2/21 /13. 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 compl iance during today's visit. Director understands the conditions, limitations, and capacity specifications of the Facility license. Director understands that children shall be visually supervised at all times. The school uses the computer sign-in/out system. Child Care Facility Roster (LIC 9040) and all were in compliance. LPA observed 3 teachers with 10 children in Transition Room 1, 1 teacher with 5 children in Transition Room 2, 2 teachers with 7 children in Preschool Room 2 and 2 teachers with 10 children in Preschool Room 3 during today's visit.

Facility evaluation report is continued on the following page: SUPERVISOR'S NAME: Sandy Knight

LICENSING EVALUATOR NAME: Shan Tan

LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (408) 324-2148

TELEPHONE: (408) 334-8321

DATE: 11/09/2011

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

FACILITY REPRESENTATIVE SIGNATURE:

4v1vv DATE: 11 /09/2011

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 2

J STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY

·J CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

FACILITY VISIT CHECKLIST CHILD CARE CENTERS AND INFANT CENTERS

Review facility file prior to visit Check to see that the following information has been updated , if required , and contained in the file Indicate the date the information was submitted to the licensing agency in the space provided for each item

~(i A,VI I _p -VI {J~A·IA (__a r.p pcP·~~fl- ,. requested.

4)44-oo;qs LICENSE ANNIVERSARY DATE DATE DATE

ON FILE REQUESTED RECEIVED

Application Information (LIC 215) / Criminal Record Clearance and Child Abuse Index Checks (LIC 198) (updated for current staff subject to fingerprint requirements)

Licensee Affidavit Regarding Persons Exempt From Fingerprint Requirements (if not on LIC 500)

Administrative Organization (LIC 309t \/ Estimated Monthly Operating Budget (LIC 401 ), Budget Information (LIC 420), Financial Statement and Information (LIC 403, LIC 404)

Articles of Incorporation, Constitution and Bylaws (if applicable)

Partnership Agreement (if applicable)

Designation of Administrative Responsibility (LIC 308)* E~\A ~ h11 Jn v Personnel Report (LIC 500) Updated* ( .2c~ / ) Facility Floor/Plot Plan (LIC 999)

Verification of Qualifications of Facility Director

Emergency Disaster Plan (LIC 610) v Disaster and Fire Drills (every 6 months)

Plan of Operation

Admissions Policies and Procedures/Fee Schedule

Health Screening Report- Facility Personnel (LIC 503)

Daily Activity Schedule

Fire Clearance (consistent with terms and limitations of license)

Bacteriological Analysis of Private Water Supply (if applicable) -----License Fee Received !;t.._(Q. tc-t~-NOTES AND COMMENTS

Posting : License, Emergency Plan , Earthquake, Parents' Rights Poster, Personal Rights , Menus, Activity List , Car seat Law

Waiver?

Bathrooms(working/clean)? \,.- Toys/Carpet(clean)? , /

1st Aid Kit? -ea_c__4_. 1"-<:~ Isolation of Sick Children? Medication?

~(w/hot & cold water)? --/ t2 ~t,t,d"-t ( Food Pre/Plan/Dishes? \/'

_E_n_ou~g~h_F_o_o_d~, {d_a_te __ cu_r_re7n~t)?_. ~~/ ________________________ S_o_lid_W __ as_t_ed __ C_on_t_ai_ne_r_s?_. ~J~Lt~a~r-~~1~~~-~~~~eA fL Outdoor: Fenced? Bodies of Water? N-v Play equipment? L/ Sufficient Resilient? 3~ ~ fC'Y.. ~d piNt..... Pt-J:fb-tT'

}

Infant: Changing Table? Needs & Services Plan? Daily Log( diaper change, feeding)?

Bottles/Food Stored & Labeled Correctly?

Care & Supervision?

LIC 9118 (11/03) *Other verifying documents may be substituted for these LIC forms

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

FACILITY NAME: TAMIEN CH ILD CARE CENTER

DEFICIENCY INFORMATION FOR THIS PAGE:

Deficiency Type POC Due Date I DEFICIENCIES Section Number

1 Ch ild's Records. A signed consent form for Type B 2 emergency medical treatment shall be in the chi ld's

07/31/2013 3 record unless §101220(f) is applicable. 4

Section Cited 5 Most of the children are missing the Censent for 101221(b)(8)(C) 6 emergency medical treatment (LIC627) form in

7 their files.

1 2 3 4 5 6 7

1 2 3 4 5 6 7

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, __ ;

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131

FACILITY NUMBER: 434400195 VISIT DATE: 07/11/2013

PLAN OF CORRECTIONS(POCs)

The director needs to provide the forms to the parents and keeps the signed forms in the children's file by 7/31 /13.

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: Sandy Knight

LICENSING EVALUATOR NAME: Shan Tan

LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (408) 324-2148

TELEPHONE: (408) 334-8321

DATE: 07/11/2013

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2013

LIC809 (FAS) - (06/04) Page: 2 of 2

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

FACILITY EVALUATION REPORT CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131

FACILITY NAME: TAMIEN CHILD CARE CENTER ADMINISTRATOR: OSTROWSKI , MARY

FACILITY NUMBER: FACILITY TYPE:

434400195 850

(408) 271-1980 95110

07/11 /2013 10:45 AM 01 :20PM

ADDRESS: 1197 LICK AVENUE TELEPHONE: CITY: SAN JOSE STATE:CA

CENSUS: 36 UNANNOUNCED

ZIP CODE: CAPACITY: 84 DATE: TYPE OF VISIT: Annual/Random TIME BEGAN: MET WITH: Erin Subala TIME COMPLETED:

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NARRATIVE LPA Shan Tan met with director Erin Subala for an Annua l Random visit in this facility. LPA observed that all the posting materials are posted. The school has computer sign in/out procedures. LPA toured the inside and outside of the facility. LPA observed no bodies of water. The director said that there were no weapons/ firearms on the premises. Medications, poisons and cleaning items are stored inaccessible to the children. Today, no children were on medications. LPA observed clean furniture , floors and play equipment. Playground equipment was in good condition . The outdoor playground surface was safe and in good condition . There was sufficient resilient material of poured foam rubber and sands under the play structure. Bathrooms were in good condition. Food preparation area in each room was clean & food was stored appropriately. Containers for solid waste had tight fitting covers.placing near the diaper changing tables. Drinking water was available both indoors & out via water fountains/pitchers . LPA observed no rodents , insects or flies . LPA observed center to be in compliance of capacity of the fire clearance & license, LPA observed visual supervision of children. 1 teacher was with 6 children in Transition Room 2, 2 teachers with 12 children in Toddler Playground and 2 teachers with 18 children in the Preschool Playground. The teacher/child ratios were met. LPA reviewed 10 files of children which had form LIC700, Identification & Emergency Information. LPA observed the required health screening in 4 staff files, and viewed the educational background for 2 staff. LPA observed that all the staff and director have current pediatric certifications CPR and First Aid which expires 2/18/15. LPA discussed the Healthy Beverage Act, AB633 requirements on A violations and Zero Tolerance $150 Immediate civil penalty with the director. A review of staff records indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record & child abuse index clearances or exemptions. LPA also reminded the director of the applicable civil penalties for those adults who have not received fingerprint clearances are not associated to the license & who come in contact with or provide care & supervision to the children. Penalty amounts: $100 per person per day, minimum of $100 to a maximum of $500 per person for an initial violation & a minimum of $100 to a maximum of $3000 per person for any subsequent violations within a 12 month period. Director Subala stated that since December, 2012 the school has no longer had military children in care. Deficiency was cited on next page. Notice of site visit was issued and must be posted for 30 days.

SUPERVISOR'S NAME: Sandy Knight TELEPHONE: (408) 324-2148

TELEPHONE: (408) 334-8321 LICENSING EVALUATOR NAME: Shan Tan

LICENSING EVALUATOR SIGNATURE:

DATE: 07/11 /2013

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11 /2013

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131

08/28/2013

TAMIEN CHILD CARE CENTER 434400195 PO BOX 9177 WATERTOWN, MA 02471

Letter of Deficiency Citations Cleared Dear Licensee,

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

The following deficiencies, initially cited during a visit on 07/11/2013, have been cleared:

Section Cited: 101221(b)(8)(C) Date Due: 07/31/2013 Plan of Correction: Corrections: The director needs to provide the forms to the parents and keeps the Reviewed files in the facility on signed forms in the children's file by 7/31/13. 8/27/13.

Clearance Date: 08/28/2013

· Received 4 copies through fax today.

LICENSING EVALUATOR NAME: Shan Tan

LICENSING EVALUATOR SIGNATURE:

De

TELEPHONE: (408) 334-8321

DATE: 08/28/2013

This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS)- (04/05) Page: 1 of 1

I ' ---

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

FACILITY NAME: TAMIEN CHILD CARE CENTER

DEFICIENCY INFORMATION FOR THIS PAGE:

Deficiency Type POC Due Date I DEFICIENCIES Section Number

1 Ch ild's Records. A signed consent form for Type B 2 emergency medical treatment shall be in the child 's

08/30/2013 3 record unless §101220(f) is applicable.

Section Cited 4 5 4 children are missing the Censent for emergency

101221(b)(8)(C) 6 medical treatment (LIC627) form in their fi les. 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

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131

FACILITY NUMBER: 434400195 VISIT DATE: 08/27/2013

PLAN OF CORRECTIONS(POCs)

The director needs to provide the forms to the parents and keeps the signed forms in the children's file by 8/30/13.

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: Sandy Knight TELEPHONE: (408) 324-2148

LICENSING EVALUATOR NAME: Shan Tan TELEPHONE: (408) 334-8321

LICENSING EVALUATOR SIGNATURE:

~ DATE: 08/27/2013

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2013

LIC809 (FAS)- (06/04) Page: 2 of 2

I STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

FACILITY NAME: TAMIEN CHILD CARE CENTER ADMINISTRATOR: OSTROWSKI , MARY ADDRESS: 1197 LICK AVENUE CITY: SAN JOSE CAPACITY: 84

STATE:CA CENSUS:

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131

FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE:

TYPE OF VISIT: POC UNANNOUNCED TIME BEGAN:

434400195 850

{408) 271 -1980 95110

08/27/2013 11 :35 AM 12:40 PM MET WITH: Erin Subala TIME COMPLETED:

NARRATIVE 1 Licensing Program Analyst (LPA) Shan Tan conducted an unannounced Plan of Correction visit to the facility. 2 LPA toured the center. LPA observed 2 teachers supervising 9 napping children in Room 21 , 2 teacher with 3 14 napping children in Room 22 and 2 teachers with 17 napping children in Room 25. The teacher/child 4 ratios were met today. 5 6 Checked deficiencies cited on 7/11/13: 7 Child's Records --The director Subala stated that she has provided the Type "B" deficiency and the Consent 8 for emergency medical treatment (LIC627) form to all the parents. However, 3 children on the 7/11 visit list 9 have left the center. Today, LPA has reviewed the children's files. LPA observed that 4 children are still 10 missing the LIC627 forms in their files. 11 12 The deficiency has not been corrected. The director stated that she will provide the forms to the parents and 13 will fax the signed form to the licensing office in this week. 14 15 16 Notice of Site Visit was issued and must be posted for 30 days. 17 18 19 20 21 22 23 24 25

SUPERVISOR'S NAME: Sandy Knight

LICENSING EVALUATOR NAME: Shan Tan

LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (408) 324-2148

TELEPHONE: (408) 334-8321

DATE: 08/27/2013

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2013

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 2

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131

08/28/2013

TAMIEN CHILD CARE CENTER 434400195 PO BOX 9177 WATERTOWN, MA 02471

Letter of Deficiency Citations Cleared Dear Licensee,

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

The following deficiencies, initially cited during a visit on 08/27/2013, have been cleared :

Section Cited: 101221(b)(8)(C) Date Due: 08/30/2013 Plan of Correction: Corrections: The director needs to provide the forms to the parents and keeps the Received 4 copies of the signed

Clearance Date: 08/28/2013

signed forms in the children's file by 8/30/13. LIC627 forms via fax.

LICENSING EVALUATOR NAME: Shan Tan

LICENSING EVALUATOR SIGNATURE:

The deficiency is cleared .

TELEPHONE: (408) 334-8321

DATE: 08/28/2013

This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS)- (04/05) Page: 1 of 1

STATE OF CALIFORNIA · HEALTH AND HUMAN SERVICES AGENCY

San Jose Child Care 2580 North First St., Ste 300 SanJose, CA 951 31

08/23/2007

TAMIAN CHILD CARE CENTER 434400195 PO BOX 9177 WATERTOWN, MA 02471

Letter of Deficiency Citations Cleared

Dear Licensee,

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

The following deficiencies, initially cited during a visit on 08/07/2007, have been cleared :

Section Cited : 101239(n) Plan of Correction: Proof of purchase of 16 mats to be sent to licensing office by 08/21/07.

Section Cited : 101227(a)(1) Plan of Correction: The staff immediately removed the expired items from the refrigerator and discarded them. A written plan to be submitted to CCL to ensure that all expired items are removed from the refrigerator by 08/14/07.

LICENSING EVALUATOR NAME: Marilou Monico

LICENSING EVALUATOR SIGNATURE: I

Date Due: 08/21/2007 Corrections: Clearance Date: Received proof of purchase of 32 mats 08/14/2007 including the mats for the infant program.

Date Due: 08/1 4/2007 Corrections: Received a written plan of correction stating that the staff from each room will go through the refrigerator every Friday at closing and dispose of any milk that will expire before the next business day.

Clearance Date: 08/14/2007

TELEPHONE: (408)334-8549

DATE: 08/23/2007

This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) - (04/05) Page: 1 of 1

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY

CIVIL PENALTY ASSESSMENT

FACILITY NAME

TAMIAN CHILD CARE CENTER FACILITY ADDRESS

1197 LICK AVENUE STATE

LICENSEE(S)/OPERATOR

BRIGHT HORIZONS CH ILDREN'S CENTERS

LICENSED FACILITY

DATE

CITY

ZIP CODE

FACILITY NUMBER

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

San Jose Child Care, 2580 North First St., Ste 300 San Jose, CA 95131

05/09/2008

SAN JOSE

95110

434400195

Civil penalties can be assessed against any faci lity which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1548, 1568.0822, 1569.49, and 1569.99. You are hereby notified that a civil penalty has been assessed.

The above facil ity has been found in violation of the California Code of Regulations, Title 22 , Divisions 6, and/or 12, Section(s) 101239 and/or Cal ifornia Health and Safety Code , Chapters 3, 3.01, 3.2, 3.4, and 3.5 Section(s)

A Facil ity Evaluation Report (LIC 809) was issued on 05/09/2008 giving notice that fa ilure to correct the above vio lation(s) would result in a civil penalty.

Because you failed to make the corrections specified on the LIC 809, a civil penalty of $0.00 is assessed for the D x period from through .

D x A civil penalty of $50 per violation per day, up to a maximum of $150 per day will be assessed . This will continue unti l correction(s) are made to comply with the licensing laws, regu lations, and approval of the California Department of Social Services or authorized licensing agency.

12_<;] x Because you repeated a violation of the same subsection with in a 12 month period ,an immediate civil penalty of $150.00 is assessed for 05/09/2008 , the day the deficiency was cited. D x Al l Facility Types: Second citation within a 12 month period; an immediate civil penalty of $150 per violation

then $50 per day per vio lation until corrections are made.

D x Residential Care Faci lity for the Elderly (RCFE), Res idential Care Faci lity for the Chronically ILL (RCF-CI}: Third citation with in 12 month period; an immediate civil penalty of $1,000 per violation then $100 per day per vio lation until corrections are made.

0 x Family Chi ld Care Homes (FCCH). Child Care Centers (CCC}, Community Care Faci lity (CCF): Third citation within 12 month period; an immediate civil penalty of $150 per violation then $150 per day per violation until corrections are made.

0 x Violations which resu lt in injury, sickness, or death An immediate civil penalty of $150 per vioation and then $150 per day per violation until corrections are made.

YOU WILL RECEIVE A BILL IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL! NAME OF LICENSING PROGRAM ANALYST Marilou Monico SIGNATURE OF LICENSING PROGRAM ANALYST

NAME OF FACILITY REPRESENTATIVE!TITLE SIGNATURE OF FACILITY REPRESENTATIVE

mcu;:t &

I vi/!Vv f!lV

SUPERVISOR REVIEW SIGNATURE (FOR INTERNAL USE ONLY)

LIC421 (FAS) • (05/06)

DATE 05/09/2008

TITLE

Page: 1 of 2

OS~ Community Care Licensin~-./ CIVIL PENALTY ASSESSMENT FORM

Part One: To Be Completed By The LPA: LPA Name: _f!!.Arni ___ , _~-=--------

Facility Name: ·r ~ eA.k:/ ~ ce.~Y #: L/ ?'-f<ft)o/cr~- Date Visit Made: {Y5,f oq; oJ

First Tier

Section#

FIRST OFFENSE* * 1 0-Day Visit Due

By:------

$50 Per Violation Starting Day After

P.O.C. Date

with a maximum of $150 a day

Citation Date: I I ---P.O.C. Date: I I ---C.P. Start: _ /_ /_

C.P. Stop: : _/_/_

Total Days= ___ _

X$50=$ _____ __

Second Tier

Section# i01 J.. 3 q

SECOND OFFENSE* WITHIN 12 MONTHS

$150 Immediate Penalty Per Violation

then $50 a day for each Violation thereafter

1st Cite Date: Of{ I 07 1_Q_? 2nd Cite Date:~ I 0 CZI_E_! Day 1 =oS'J_Qj oJ,-Day 1 = $150

C.P. Stop:fJ.£_/_QJ 0 ~

Total Days = ---'-·---~-­Days@ $50 = 0 (count from 2nd Day)

Total Penalty= $150 (D1 )

+ ( 0 Days X $50) = Total Penalty=$ j~!J

PART TWO: SUPERVISOR REVIEW

Third Tier

Section#

THIRD OFFENSE* WITHIN 12 MONTHS OF LAST OFFENSE

$150 Immediate Penalty Per Violation then $150 a day for

each Violation thereafter

1st Cite Date: I I ---2nd Cite Date : I I ----3'd Cite Date: _/_/_

C.P. Stop: _/_/_

Total Days = ___ _

X$150=$ ___ _

(Total Penalty)

----PIVIL PENALTY IS CORRECT. POC VISIT MADE ON TIME.

Criminal Record

Clearance

Section#

Fingerprints/C.i\ .I.C. not cleared or

associated prior to presence in the facility

$100 Immediate Penalty Per Person without Clearances

associated to Facility

Citation Date: _ /_ /_

No. Of Persons Not In Compliance= ___ _

Maximum of five days for the 1st Violation

Total Days= __

X $100 = $ ___ _

(Total Penalty)

A maximum of 30 days for subsequent Violations

Total Days= __

X $100 = $ ___ _

(Total Penalty)

_ _ CIVIL PENALTY AS SHOWN ON LIC 421 IS CORRECT. PLEASE AMEND/CORRECT AND SEND CORRECTED COPY TO .LICENSEE VIA CERTIFIED MAIL, RETURN RECEIPT REO.

_ _ VISIT MADE ON TIME. CIVIL PENALTY CANNOT BE ASSESSED. PLEASE NOTIFY LICENSEE BY PHONE.

{J~~ SUPERVISOR'S NAME: SJ DO-CC 05/10/05

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY ,_./ CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

NOTICE OF CIVIL PENALTIES DUE

lt2'i Initial Invoice [] Final Notice

INVOICE NO. 07001421 DISTRICT OR COUNTY OFFICE NUMBER ___ o_? _______ _

FACILITY NAME

CITY STATE

1197 LICK AVENUE ZIP CODE I

LFI~SC~A=LY~EA~R=-------+D=M~E~LI~C4=22~S=EN~T~-----j } 007 -2008 05/14/2008 FACILITY TYPE I PENALTY PCA CODE

DCC . 84-850

TAMIAN CHILD CARE CENTER FACILITY ADDRESS

SAN JOSE, CA 95110 I FACILITY NUMBER

434400195 LICENSEEIS) OR UNLICENSED FACILITY OPERATOR

BRIGHT HORIZONS CHILDREN'S CENTERS

STATE CITY -------------~ 17.1 Qj OSS II

ADDRESS

PO BOX 9177

WATERTOWN , MA 02471 ------------------~

The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods.

The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed faci lity which fails to take corrective action within prescribed time periods.

The California Health and Safety Code, Sections 1522, 1568.09 , 1569.17, 1596.871 , and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements.

Your facility has been found in violation of Community Care Licensing statutes and regulations.

Failure to correct the deficiency(ies) cited on the Licensing Report (LIC 809 or LIC 9099) dated_~~9~~~~~~------------­has resulted in the following civil penalty assessment of:

Penalty Amount Due . . . ... . . .. . . .. . . . . ... . . . ... .. ... .. . .. __________________________________ jj.§_Q.:.Q.Q.

Less Payment(s) Received . . . .... .... . ............ . .. .. . . . -----------------------------------------

BALANCE DUE ... . .... . .. ... .. .. ...... . .. .... . .. ...... . __________________________________ j_1§~~QQ

Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check.

DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING- CC

2580 NORTH FIRST STREET, SUITE 300

SAN JOSE, CA 95131

FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING:

• SMALL CLAIMS COURT ACTION

• LICENSE DENIAL, SUSPENSION, OR REVOCATION

• SEIZURE OF PERSONAL INCOME TAX REFUNDS LIC 422 (3102) (PUBLIC)

Control Number 07-CC-20080501U92736 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

FACILITY NAME: TAMIAN CHILD CARE CENTER DEFICIENCY INFORMATION FOR THIS PAGE:

Deficiency Type POC Due Date I DEFICIENCIES Section Number

1 FIXTURES, FURNITURE, EQUIPMENT AND Type A 2 SUPPLIES- LPA's observed that scissors used by

05/09/2008 3 the preschool children were not age appropriate.

Section Cited 4 The scissors were meant for children 5 years and 5 up.

101239(m) 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

1 2 3 4 5 6 7

1 2 3 4 5 6 7

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

San Jose Child Care, 2580 North First St., Ste 300 San Jose, CA 95131

FACILITY NUMBER: 434400195

VISIT DATE: 05/09/2008

PLAN OF CORRECTIONS(POCs)

Site Director already removed the scissors in the preschool program and replaced them with plastic age appropriate scissors.

Deficiency corrected.

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: Sandy Knight

LICENSING EVALUATOR NAME: Marilou Monico

LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (408)324-2148

TELEPHONE: (408)334-8549

! ~ ~ DATE' 05/0912008

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2008

This Notice must be posted for 30 days

LIC9099 (FAS) • (06/04) Page: 2 of 3

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

San Jose Child Care, 2580 North First St., Ste 300 San Jose, CA 95131

This is an official report of an unannounced visiUinvestigation of a complaint received in our office on 05/01/2008 and conducted by Evaluator Marilou Monico

PUBLIC COMPLAINT CONTROL NUMBER: 07-CC-20080501092736

FACILITY NAME: TAMIAN CHILD CARE CENTER ADMINISTRATOR:OSTROWSKI , MARY ADDRESS: 1197 LICK AVENUE CITY: SAN JOSE CAPACITY: 84

MET WITH: Mary Ostrowski

ALLEGATION(S):

STATE: CENSUS: 42 UNANNOUNCED

FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED:

1 PHYSICAL PLANT- Scissors that preschool children use are not age appropriate. 2 3 4 5 6 7 8 9

INVESTIGATION FINDINGS:

4344001 95 850

(408) 271-1980 95110

05/09/2008 02:00PM 03:15PM

1 LPA's Marilou Monico and Monica Greenleaf met with Site Director, Mary Ostrowski and discussed the 2 allegations. Site Director stated that she was not aware that the scissors were not age appropriate until a 3 parent brought it to her attention . A three year old child was cut in the ear by another classmate by scissors 4 meant for children ages 5 and up. Site Director researched the issue and ordered new age appropriate 5 scissors the next day. She also ordered new age appropriate scissors for the other classrooms. Finding for the 6 above allegation is SUBSTANTIATED. 7 LPAs discussed the requirements of AB 633 to Site Director, Mary Ostrowski and provided her the fact sheet 8 and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and she understands the 9 requirements. 10 11 Deficiency cited on next page. 12 NOTICE OF SITE VISIT WAS POSTED AND MUST REMAIN POSTED FOR 30 DAYS. 13

Substantiated Estimated Days of Completion:

SUPERVISOR'S NAME: Sandy Knight

LICENSING EVALUATOR NAME: Marilou Monico

LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (408)324-2148

TELEPHONE: (408)334-8549

DATE: 05/09/2008

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2008

This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) • (06/04) Page: 1 of 3

All POC Have Been Cleared STATE OF CALIFORNIA · HEALTH AND HUMAN SERVICES AGENCY

CLEARED DEFICIENCIES

FACILITY NAME: TAMIAN CHILD CARE CENTER

POC Due Date I PLAN OF CORRECTIONS(POCs) Section Number

03/30/2007 1

101229(a) 2 3 Site director will submit a written plan to ensure that chi ldren 4 are visually supervise at all times. Proof of correction will be 5 submitted to CCL office by due date. 6 7

03/30/2007 1

Section Cited ~ Site Director will submit a written plan to CCI office to make 1 01212(d)

4 ~ure unusual incident/injury has to be reported within 24 hours

5 ~rom the time of occurrence followed by a written report wi th in

6 7 calendar days to CCL office.

7

1

Section Cited 2 3 4 5 6 7

1

Section Cited 2 3 4 5 6 7

1

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

San Jose Child Care, 111 N Market, #300 San Jose, CA 95113

FACILITY NUMBER: 434400195

VISIT DATE: 03/20/2007

Date Cleared I Comments

03/28/2007 2 Received plan - an on-going training to 3 be completed 4/6/07. 4

03/28/2007 1 Received plan by having Admin Team 2 review and follow up all accident reports 3 to determine if any medical follow up is 4 required .

1 2 3 4

1 2 3 4

STATE OF CALIFORNIA · HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

San Jose Child Care 111 N Market, #300 San Jose, CA 95113

04/12/2007

TAMIAN CHILD CARE CENTER PO BOX 9177 WATERTOWN, MA 02471

Letter of Deficiency Citations Cleared Dear Licensee,

The following deficiencies, initially cited during a visit on 03/20/2007, have been cleared :

Section Cited: 1 01229(a) Date Due: 03/30/2007 Plan of Correction : Corrections: Clearance Date: Sile director will submit a written plan to ensure that children are Received plan - an on-going training to 03/28/2007 visually supervise al all times. Proof of correction will be submitted to be completed 4/6/07. CCL office by due date.

Section Cited : 101212(d) Plan of Correction: Site Director wil l submit a written plan to CCI office to make sure unusual incidenVinjury has to be reported within 24 hours from the time of occurrence followed by a written report within 7 calendar days to CCL office.

Date Due: 03/30/2007 Corrections: Received plan by having Admin Team review and follow up all accident reports to determine if any medical follow up is required .

Clearance Date: 03/28/2007

LICENSING EVALUATOR NAME: Milagros Aguas

LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (408)277-2055

DATE: 04/12/2007

Cleared POC Letter (FAS) • (04/05) Page: 1 of 1

S T A 1 E OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENC---.._/ CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

FACILITY VISIT CHECKLIST CHILD CARE CENTERS AND INFANT CENTERS

Review facility file prior to visit. Check to see that the following information has been updated, if required , and contained in the file . Indicate the date the information was submitted to the licensing agency in the space provided for each item requested.

- -< d '<-1-'-t oot cr s LICENSE ANNIVERSARY DATE

DATE DATE {~ CCC ON FILE REQUESTED RECEIVED

Application Information (LIC 215) ~/~~~ .~.( / -- C~~~aiR~~ord Cleara~ce and c hild A ~se Index Che~ks (LIC 198) (updated for current

-staff subject to fingerprint requirements)

1-- -- --- - --- ----- --- ---------- --- --Licensee Affidavit Regarding Persons Exempt From Fingerprint Requirements (if not on LIC 500)

-- -- ----- - ------------ ---- ---- - ----------------------- -- -·----- -Administrative Organization (LIC 309)* _}j_illk_ ______________ --- v

-· ··-- -- ----- -···--------··----·-------- -------- ··- ----Estimated Monthly Operating Budget {LIC 401 ), Budget Information (LIC 420), Financial /

- S~!_eme!::~ ~~~-~~.!<?..!"mation (~ IC 403, LIC 404) ------- ·-· ----· Articles of Incorporation, Constitution and Bylaws (if applicable) ~ -----·-- -------- ---------- ---·---- r------·-Partnership Agreement (if applicable) ·f..J / A -· -------- --Designation of Administrative Responsibility {LIC 308)* 11/ta/o ~ /~r ':J. S...JocJq

o----- ----- ~~r_~O.~~e; Repo~J.~~~~~-Ol_~d!~ed* __ ?~Cc 12:::;1:::{ e~~' ~b.s-: ~ v

----Facility Floor/Plot Plan (LIC 999) --~--·- ·--· ................ -... ·--·------------ ---- -------- --- -·-- ____ .. ________ - ---------Verification of Qualifications of Facility Director

--~~~~~-~~~~-~-i~~~;; Pia~(~-~~-;~} ---;;7"k7-1?·----------- -- ------·---- ---------------- - -----

~ ·-- ------ ------·- --· --------·-····- - --- --------- -------·-···- ----- ·-· --Disaster and Fire Dri lls (every 6 months)

- - ---------------------- ---- ------ ------- --- -- - ------ ------ -Plan of Operation

----------· -Admissions Policies and Procedures/Fee Schedule s/ -- -·------ --- ----Health Screening Report- Facility Personnel {LIC 503)

---- -------·- --- --------------- --·- r-----Daily Activity Schedule .......--

- ----------------·-- ------- ·-·-- -------------------·---- -- ----------··--··----· -· .. ·------ - -Fire Clearance (consistent with terms and limitations of license) .. Y-__ ----. ------- -------------------- ---------- ------- -- -- ---·

Bacteriological Analysis of Private Water Supply (if applicable) 0_..6 _____ - --- ·- ·-· . ·-·. ·-··----------- . ---------------.. ------ ------- -----·-- --- ---

License Fee Received - ·-· ..

NOTES AND COMMENTS - -----··----·--------

--------·--· ------

- -·------------------·

--------- ------------------------------------

LIC 9118 (11 103) *Other verifying documents may be substituted for these LIC forms

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

FACILITY NAME: TAMIAN CHILD CARE CENTER

DEFICIENCY INFORMATION FOR THIS PAGE:

Deficiency Type POC Due Date I DEFICIENCIES Section Number

1 FIXTURES, FURNITURE, EQUIPMENT AND Type A 2 SUPPLIES

08/21/2007 3 LPAs observed that 16 mats in the preschool

Section Cited 4 rooms were ripped and with exposed foams. 5

101239(n) 6 7

1 FOOD SERVICE: Type A 2 LPAs observed two expired containers of milk in

08/14/2007 3 the refrigerator located in Preschool Room 2.

Section Cited 4 5

1 01227(a)(1) 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

1 2 3 4 5 6 7

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

San Jose Child Care, 2580 North First St., Ste 300 San Jose, CA 95131

FACILITY NUMBER: 434400195 VISIT DATE: 08/07/2007

PLAN OF CORRECTIONS(POCs)

Proof of purchase of 16 mats to be sent to licensing office by 08/21/07.

The staff immediately removed the expired items from the refrigerator and discarded them. A written plan to be submitted to CCL to ensure that all expired items are removed from the refrigerator by 08/14/07.

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: Michele Wong

LICENSING EVALUATOR NAME: Marilou Monico

LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (408)324-2151

TELEPHONE: (408)334-8549

DATE: 08/07/2007

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

FACILITY REPRESENTATIVE SIGNATURE:

~&~ DATE: 08/07/2007

This Notice must be posted for 30 days

LIC809 (FAS) • (06/04) Page: 2 of 2

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

FACILITY NAME: TAMIAN CHILD CARE CENTER ADMINISTRATOR: OSTROWSKI, MARY ADDRESS: 1197 LICK AVENUE CITY: SAN JOSE CAPACITY: 84 TYPE OF VISIT: Required - 5 Year MET WITH: Mary Ostrowski

STATE:CA CENSUS: 43 UNANNOUNCED

NARRATIVE

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

San Jose Child Care, 2580 North First St., Ste 300 San Jose, CA 95131

FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED:

434400195 850

(408) 271-1980 95110

08/07/2007 08:20AM 05:30PM

1 LPAs Marilou Monico and Liz Berumen conducted an unannounced comprehensive 5 year required visit. Met 2 with Site Director, Mary Ostrowski. LPAs toured the faci lity both inside and out, as well as reviewed staff and 3 children's files. Review of staff records indicates that all staff or other individuals who require caregiver 4 background checks have received criminal record and child abuse index clearances/exemptions. One 5 teacher's passport was completed. The teacher/child ratio was in compliance during the visit. LPAs observed 6 the required posted materials, including the facility license, emergency disaster plan , parents and personal 7 rights information. The Director provided a copy of updated Personnel Report and Emergency Disaster Plan . 8 Heating, lighting and ventilation were adequate. Drinking water was readily available in each room, and in the 9 outdoor activity area. Sharp objects and toxic materials were made inaccessible to children . 10 11 LPAs discussed the requirements of AB 633 to Site Director, Mary Ostrowski and provided her the fact sheet 12 and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and she understands the 13 requirements . 14 15 The following forms need to be submitted to CCL Office: 16 1) Updated Board Resolution by 09/07/07 ...1 17 2) Updated Designation of Administrative Responsibility (LIC 008) by 09/07/07 18 3) Updated Application for a Child Care Center License (LIC ·200A) 09/07/07 19 20 As a result of this visit, deficiencies are cited according to Title 22 , Division 12, Chapter 1 of the CCR on the 21 following pages: 22 23 24 25 NOTICE OF SITE VISIT WAS POSTED AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Michele Wong

LICENSING EVALUATOR NAME: Marilou Monico

LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (408)324-2151

TELEPHONE: (408)334-8549

DATE: 08/07/2007

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

FACILITY REPRESENTATIVE SIGNATURE:

~a-~ DATE: 08/07/2007

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 2

STATE 01' CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY

CIVIL PENAL TV ASSESSMENT

FACILITY NAME

TAMIAN CHILD CARE CENTER I'ACILITY ADDRESS

1197 LICK AVENUE STATE

CA LICENSEE(SJ/OPERATOR

BRIGHT HORIZONS CHILDREN'S CENTERS

LICENSED FACILITY

DATE

CITY

I ZIP CODE

I'ACILITY NUMBER

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

san Jose Cllikl ca ... , 111 N Marka1 #300 san Jose, CA 5&113

07/05/2002

SAN JOSE

95110

434400195

ivil penalties can be assessed against any facility which fails to take corrective action within prescribed tim periods, per California Health and Safety Code Sections 1548, 1568.0822, 1569.99. You are hereby notified that a ivil penalty has been assessed.

he above facility has been found in violation of the California Code of Regulations, Title 22, Divisions 6, and/or 12,

ection(s) 101216 (g) (2) and/or California Health and Safety Code, Chapters 3, 3.01 , 3.2, 3.4, and 3.5 Section(s)

A Facility Evaluation Report (LIC 809) was issued o!Q7/05/2002 giving notice that failure to correct the above violation(s) would result in a civil penalty.

Because you failed to make the corrections specified on the LIC 809, a civil penalty c$0.00 is assessed for the D period from through .

D A civil penalty of $50 per violation per day, up to a maximum of $150 per day will be assessed. This will continue until correction(s) are made to comply with the licensing laws, regulations, and approval of the California Department of Social Services or authorized licensing agency.

k2J Because you repeated a violation of the same subsection within a 12 month period, an immediate civil penalty of $150.00 is assessed for 07/05/2002, the day the deficiency was cited.

k2J All Facility Types: Second citation within a 12 month period; an immediate civil penalty of $150 per violation then $50 per day per violation until corrections are made.

0 Residential Care Facility for the Elderly (RCFE), Residential Care Facility for the Chronically ILL (RCF-CI): Third citation within 12 month period; an immediate civil penalty of $1 ,000 per violation then $100 per day per violation until corrections are made.

0 Child Care Centers, Community Care Facility (CCF)Third citation within 12 month period; an immediate civil penalty of $150 per violation then $150 per day per violation until corrections are made.

D Violations which result in injury, sickness, or death: An immediate civil penalty of $150 per violation and then $150 per day per violation until corrections are made.

YOU WILL RECEIVE A BILL IN THE MAIL.

DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL!

NAME 01' LICENSING PROGRAM ANALYST NAME 01' I'ACILITY REPRESENTATIVEITrTLE

Carla Baldwin

LIC421 (FASJ • (41001 Page: 1 of 2

STATE 01' CALII'OI'INIA • HI.ALTH AND HUMAN UI'IVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

FACILITY NAME: TAMIAN CHILD CARE CENTER

DEFICIENCY INFORMATION FOR THIS PAGE:

Deficiency Type DEFICIENCIES POC Due Date I Section Number

TypeS 1 PERSONAL RIGHTS: Child# 9 is missing a signed Personal 2

07/1912002 3 Rights form in file.

Section Cited 4 1 01223(1 )(a) 5

6 7

TypeS 1 ADMISSION PROCEDURES: Child# 9 is missing a siged copy 2

07 tr:15I2002. 3 of the Parent's Rights form in file.

Section Cited 4 101218.1 (b) (1) 5

6 7

TypeS 1 PERSONNEL REQUIREMENTS: Staff# 11, and 13 are 2

07/1912002 3 missing a Health Screening report in their files. Staff# 12, and

Section Cited 4 13 are missing proof of a negative TS test in file.

101216 (g) (2) 5 6 7

1 Section Cited 2

3 4 5 6 7

CALII'OI'INIA DIPAI'ITMINT 01' SOCIAL SII'IVICIS COMMUNITY CAPlE LICENSING DMSION

San Jose Child Care, 1t 1 N Market #300 san Jose, CAH113

FACILITY NUMBER: 434400195 VISIT DATE: 07/05/2002

PLAN OF CORRECTIONS(POCs)

1 Submit a copy of the signed Personal 2 3

Rights form to CCL by 7119/02.

4 5 6 7

1 Submit a copy of the signed Parenfs 2 3

Rights form to CCL by 7/19/CY2..

4 5 6 7

1 Submit copies of the missing Health 2 3

Screening and proof of negative TS test

4 to CCL by 7/19/CY2.. This is the second citation of this subsection in the past 12

5 months. $150 civil penalty is assessed 6 today. 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: Judith Younse

LICENSING EVALUATOR NAME: Carla B?: ~ fl~

LICENSING EVALUATOR SIGNATURE: ~/ .2_~ '

TELEPHONE: (408) 277-1174

TELEPHONE: (408) 277-2053

DATE: 07/05/2002

I acknowledge receipt of this form and understand my appeal rights as explain~ and received.

LICBOS (FAS)-(4/K) Page: lnconect data type for operator or @Function: Text expected of

STATE 01' CALII'OftNIA ·HEALTH AND HUMAN SEftVICES AGENCY CALII'OftNIA DEPAftTMENT 01' SOCIAL SEftVICES COMMUNITY CAftE LICENSING DIVISION

FACILITY EVALUATION REPORT San Jon Cltlkl Care, 111 N Marttet 11300 San Jose, CA 116113

FACILITY NAME:

TAMIAN CHILD CARE CENTER FACILITY NUMBER:

4344001.95

DIRECTOR: OSTROWSKI , MARY 1197 LICK AVENUE SAN JOSE

FACILITY TYPE: 850 (408) 271-1980

95110 ADDRESS: TELEPHONE: CITY: STATE:CA ZIP CODE:

CAPACITY: 84 CENSUS: 24 DATE: 07/05/2002 09:30AM 03:30PM

TYPE OF VISIT: Annual UNANNOUNCED TIME BEGAN: MET WITH: Mary Ostrowski, Director TIME COMPLETED:

DEFICIENCY INFORMATION FOR THIS PAGE: CIVIL PENALTY INFORMATION:

Type B Penalty Assessed

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

COMMENTS/DEFICIENCIES

LPA Carla Baldwin conducted an unannounced comprehensive annual evaluation. LPA met with Mary Ostrowski, and toured the indoor and outdoor activity areas of the facility. LPA observed the required posted materials, including the facility license, emergency disaster plan, parent•s and personal rights infonnation. LPA provided the director with the new Parent•s Rights fonn, as the center did not receive one in the mail. The center has an electronic sign-in/sign-out procedure. There was a fire extinguisher, and first aid kit in the facility. Heating, lighting, and ventilation were adequate. Drinking water was readily available in each room, and in the outdoor activity area. Arrangements have been made for the isolation and care of ill children. The trash cans used for storage of solid waste have tight fitting lids.

The licensee was provided with a preprinted copy of the Licensee Rights fonn, due to the computers inability to print both pages of the fonn.

The staff and children•s records were reviewed.

The following Title 22, Division 12, Chapter 1 deficiencies are cited as a result of todays visit:

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: Judith Younse

LICENSING EVALUATOR NAME: Carla B~ ~ fl ~ LICENSING EVALUATOR SIGNATURE: ~ ~~__:_,. __

TELEPHONE: (408) 277-1174

TELEPHONE: (408) 277-2053

DATE: 07/05/2002

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

Page: 1 of2 LICIO' (I' AS) • (4/H)

STATE OF CALIFORNIA- HEALTH AND Hl>......,A'SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

JRNIA DEPARTMENT OF SOCIAL SERVICES ~UNITY CARE LICENSING DIVISION

San Jose Child Care, 111 N Market, #300 San Jose, CA 95113

This is an official report of an unannounced visiUinvestigation of a complaint received in our office on 02/15/2007 and conducted by Evaluator Milagros Aguas

FACILITY NAME: TAMIAN CHILD CARE CENTER ADMINISTRATOR: OSTROWSKI, MARY ADDRESS: 1197 LICK AVENUE CITY: SAN JOSE CAPACITY: 84

MET WITH: Mary Ostrowski

ALLEGATION(S):

COMPLAINT CONTROL NUMBER: 07-CC-20070215155432

FACILITY NUMBER: FACILITY TYPE: TELEPHONE:

STATE: ZIP CODE: CENSUS: 10 DATE: UNANNOUNCED TIME VISIT BEGAN:

TIME COMPLETED:

434400195 850

(408) 271-1980 95110

03/20/2007 01 :30PM 04:30PM

1 NEGLECT/LACK OF SUPERVISION - Child has cut and bruise on left eye. 2 3 4 5 6 7 8 9

INVESTIGATION FINDINGS: 1 LPAs Meela Aguas and Marilou Monico met with Site Director, Mary Ostrowski for a follow-up visit. Staff were 2 interviewed. Based on information gathered, LPA is unable to prove or disprove the allegation. Finding for the 3 above allegation is INCONCLUSIVE. 4 5 6 7 8 9 10 11 12 13

Inconclusive

SUPERVISOR'S NAME: Angela Carmack

LICENSING EVALUATOR NAME: Milagros Aguas

LICENSING EVALUATOR SIGNATURE:

Estimated Days of Completion:

TELEPHONE: (408)277-1286

TELEPHONE: (408)277-2055

DATE: 03/20/2007

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

FACILITY REPRESENTATIVE SIGNATURE:

~t)~ DATE: 03/20/2007

This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) • (06104) Page: 1 of 1

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

FACILITY NAME: TAMIAN CHILD CARE CENTER

DEFICIENCY INFORMATION FOR THIS PAGE:

Deficiency Type POC Due Date I DEFICIENCIES Section Number

1 RESPONSIBILITY FOR PROVIDING CARE AND Type A 2 SUPERVISION.

03/30/2007 3 A child was injured wherein he sustained chipped

Section Cited 4 tooth and not one of the staff witnessed how it 5 happened .

101229(a) 6 7

1 REPORTING REQUIREMENTS Type A 2 ThCCLenter failed to report the unusual

03/30/2007 3 incidenUinjury where in the child sustained chipped

Section Cited 4 tooth and was seen by his Dentist. 5

1 01212(d) 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

1 2 3 4 5 6 7

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

San Jose Child Care, 111 N Market, #300 San Jose, CA 95113

FACILITY NUMBER: 434400195 VISIT DATE: 03/20/2007

PLAN OF CORRECTIONS(POCs)

Site director will submit a written plan to ensure that children are visually supervise at all times. Proof of correction will be submitted to CCL office by due date.

Site Director will submit a written plan to CCI office to make sure unusual incidenUinjury has to be reported within 24 hours from the time of occurrence followed by a written report within 7 calendar days to CCL office.

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: Angela Carmack

LICENSING EVALUATOR NAME: Milagros Aguas

LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (408)277-1286

TELEPHONE: (408)277-2055

DATE: 03/20/2007

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

FACILITY REPRESENTATIVE SIGNATURE:

&, DATE: 03/20/2007

This Notice must be posted for 30 days

LIC809 (FAS) • (06/04) Page: 2 of 2

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

FACILITY NAME: TAMIAN CH ILD CARE CENTER ADMINISTRATOR: OSTROWSKI, MARY ADDRESS: 1197 LICK AVENUE CITY: SAN JOSE CAPACITY: 84 TYPE OF VISIT: Case Management MET WITH: Mary Ostrowski

STATE:CA CENSUS: UNANNOUNCED

NARRATIVE

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

San Jose Child Care, 111 N Market, #300 San Jose, CA 95113

FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED:

434400195 850

(408) 271-1980 95110

03/20/2007 01:30PM 04:30PM

LPAs Meela Aguas and Marilou Monico Met with Site Director, Mary Ostrowski and conducted a case management visit. A report was received by CCL office in which a child got injured and sustained chipped tooth. LPAs interviewed staff and not one witnessed how it happened. The center did not report the unusual incident/injury to CCL office.

Assembly Bill 633 and Acknowledgement of Receipt of Licensing Reports (LIC 9224) form was provided and explained to the Site Director.

Deficiencies were cited during the visit

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

NOTICE OF SITE VISIT WAS ISSUED AND POSTED AND WILL REMAIN POSTED TOGETHER WITH THE A DEFICIENCIES.

SUPERVISOR'S NAME: Angela Carmack

LICENSING EVALUATOR NAME: Milagros Aguas

LICENSING EVALUATOR SIGNATURE:

~I

TELEPHONE: (408)277-1286

TELEPHONE: (408)277-2055

DATE: 03/20/2007

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

FACILITY REPRESENTATIVE SIGNATURE:

~[) DATE: 03/20/2007

This report must be available at Child Care and Group Home faci lities for publ ic review for 3 years.

LIC809 (FAS) - (06/04) Page: 1 of2