POMEROY DISTRICT PRESCHOOL

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA), Cortney Nelson, met with staff member, Ruth Hernandez, who states that Site Supervisor, Judie Stevens, is out on an errand and will return soon. Upon arrival, LPA explained purpose of visit to Ruth, follow-up on incident that occurred on 8/25/2022 and interview staff. LPA toured inside and outside of the facility and conducted COVID risk assessment. While touring outside playground, Site Supervisor, Judie, arrived to the facility. Visit today is in response to an incident that occurred that was called into the San Jose Regional Office (SJRO) by Site Supervisor, Judie, to report that on 8/25/2022 around 11:35AM a child was forgotten in the classroom after washing hands when returning from the playground. In the report, it was noted that the child was alone for approximately 2-3 minutes before returning to the classroom where all other children and staff were present. Unusual Incident Report (LIC624) was received by the SJRO on 8/26/2022 and Site Supervisor states that she additionally notified the parent of the child involved in the incident of its occurrence. LPA conducted interviews with staff involved in the incident as well as the Site Supervisor. Site Supervisor states that the typical routine is for children to be split into two groups for hand washing as the facility has inclusion program and some children may require more individualized attention. Also, there is limited sink space in classroom 21, so the group utilizes 2 additional sinks located in classroom 34. Since the incident, follow-up training has been conducted with the staff involved as well as changes in the procedure for hand washing and ratio maintenance. During todays visit, LPA discussed with Site Supervisor strategies for safe ratio management of the children and ways to ensure similar situation does not occur again in the future. Judie states that moving forward, the same 3 children will always accompany a designated staff member to room 34 for hand washing. White boards have been posted to clearly identify the number of children and staff present during the day and Site Supervisor states that walkie talkies have been ordered for utilization too. SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Cortney Nelson LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022 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 FACILITY NAME: POMEROY DISTRICT PRESCHOOLFACILITY NUMBER: 434400480 VISIT DATE: 08/31/2022 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 32LPA obtained copy of children's roster and training document (conducted 8/26/2022) signed by teachers involved in the incident during todays inspection. LPA additionally requested personnel roster (LIC500), however Site Supervisor states that she has not been able to create one yet. LPA wrote down names of all staff involved in supervision at the preschool from each program (Paraeducators and Student Adapted Instruction-SAI) instead. During todays visit, LPA additionally became aware of new Site Supervisor at the facility who states that she started at the beginning of August 2022. The department has not been made aware of the new Site Supervisor and LPA requested that she submit all required documents for review. Exit interview conducted and report was reviewed with Site Supervisor, Judie Stevens. As a result of todays inspection, deficiencies have been cited, see 809-D. A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. LPA informed Site Supervisor, Judie Stevens, that this report dated 8/31/2022, documents one Type A citation, which shall be posted for 30 consecutive days as there was immediate risk to the health, safety, or personal rights of children in care. Also, LPA informed the Site Supervisor to provide a copy of this licensing report dated 8/31/2022 that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Cortney Nelson LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022 FACILITY NAME: POMEROY DISTRICT PRESCHOOL FACILITY NUMBER: 4344

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA), Cortney Nelson, met with staff member, Ruth Hernandez, who states that Site Supervisor, Judie Stevens, is out on an errand and will return soon. Upon arrival, LPA explained purpose of visit to Ruth, follow-up on incident that occurred on 8/25/2022 and interview staff. LPA toured inside and outside of the facility and conducted COVID risk assessment. While touring outside playground, Site Supervisor, Judie, arrived to the facility. Visit today is in response to an incident that occurred that was called into the San Jose Regional Office (SJRO) by Site Supervisor, Judie, to report that on 8/25/2022 around 11:35AM a child was forgotten in the classroom after washing hands when returning from the playground. In the report, it was noted that the child was alone for approximately 2-3 minutes before returning to the classroom where all other children and staff were present. Unusual Incident Report (LIC624) was received by the SJRO on 8/26/2022 and Site Supervisor states that she additionally notified the parent of the child involved in the incident of its occurrence. LPA conducted interviews with staff involved in the incident as well as the Site Supervisor. Site Supervisor states that the typical routine is for children to be split into two groups for hand washing as the facility has inclusion program and some children may require more individualized attention. Also, there is limited sink space in classroom 21, so the group utilizes 2 additional sinks located in classroom 34. Since the incident, follow-up training has been conducted with the staff involved as well as changes in the procedure for hand washing and ratio maintenance. During todays visit, LPA discussed with Site Supervisor strategies for safe ratio management of the children and ways to ensure similar situation does not occur again in the future. Judie states that moving forward, the same 3 children will always accompany a designated staff member to room 34 for hand washing. White boards have been posted to clearly identify the number of children and staff present during the day and Site Supervisor states that walkie talkies have been ordered for utilization too. SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Cortney Nelson LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022 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 FACILITY NAME: POMEROY DISTRICT PRESCHOOLFACILITY NUMBER: 434400480 VISIT DATE: 08/31/2022 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 32LPA obtained copy of children's roster and training document (conducted 8/26/2022) signed by teachers involved in the incident during todays inspection. LPA additionally requested personnel roster (LIC500), however Site Supervisor states that she has not been able to create one yet. LPA wrote down names of all staff involved in supervision at the preschool from each program (Paraeducators and Student Adapted Instruction-SAI) instead. During todays visit, LPA additionally became aware of new Site Supervisor at the facility who states that she started at the beginning of August 2022. The department has not been made aware of the new Site Supervisor and LPA requested that she submit all required documents for review. Exit interview conducted and report was reviewed with Site Supervisor, Judie Stevens. As a result of todays inspection, deficiencies have been cited, see 809-D. A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. LPA informed Site Supervisor, Judie Stevens, that this report dated 8/31/2022, documents one Type A citation, which shall be posted for 30 consecutive days as there was immediate risk to the health, safety, or personal rights of children in care. Also, LPA informed the Site Supervisor to provide a copy of this licensing report dated 8/31/2022 that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Cortney Nelson LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022 FACILITY NAME: POMEROY DISTRICT PRESCHOOL FACILITY NUMBER: 4344

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA), Cortney Nelson, met with staff member, Ruth Hernandez, who states that Site Supervisor, Judie Stevens, is out on an errand and will return soon. Upon arrival, LPA explained purpose of visit to Ruth, follow-up on incident that occurred on 8/25/2022 and interview staff. LPA toured inside and outside of the facility and conducted COVID risk assessment. While touring outside playground, Site Supervisor, Judie, arrived to the facility. Visit today is in response to an incident that occurred that was called into the San Jose Regional Office (SJRO) by Site Supervisor, Judie, to report that on 8/25/2022 around 11:35AM a child was forgotten in the classroom after washing hands when returning from the playground. In the report, it was noted that the child was alone for approximately 2-3 minutes before returning to the classroom where all other children and staff were present. Unusual Incident Report (LIC624) was received by the SJRO on 8/26/2022 and Site Supervisor states that she additionally notified the parent of the child involved in the incident of its occurrence. LPA conducted interviews with staff involved in the incident as well as the Site Supervisor. Site Supervisor states that the typical routine is for children to be split into two groups for hand washing as the facility has inclusion program and some children may require more individualized attention. Also, there is limited sink space in classroom 21, so the group utilizes 2 additional sinks located in classroom 34. Since the incident, follow-up training has been conducted with the staff involved as well as changes in the procedure for hand washing and ratio maintenance. During todays visit, LPA discussed with Site Supervisor strategies for safe ratio management of the children and ways to ensure similar situation does not occur again in the future. Judie states that moving forward, the same 3 children will always accompany a designated staff member to room 34 for hand washing. White boards have been posted to clearly identify the number of children and staff present during the day and Site Supervisor states that walkie talkies have been ordered for utilization too. SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Cortney Nelson LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022 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 FACILITY NAME: POMEROY DISTRICT PRESCHOOLFACILITY NUMBER: 434400480 VISIT DATE: 08/31/2022 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 32LPA obtained copy of children's roster and training document (conducted 8/26/2022) signed by teachers involved in the incident during todays inspection. LPA additionally requested personnel roster (LIC500), however Site Supervisor states that she has not been able to create one yet. LPA wrote down names of all staff involved in supervision at the preschool from each program (Paraeducators and Student Adapted Instruction-SAI) instead. During todays visit, LPA additionally became aware of new Site Supervisor at the facility who states that she started at the beginning of August 2022. The department has not been made aware of the new Site Supervisor and LPA requested that she submit all required documents for review. Exit interview conducted and report was reviewed with Site Supervisor, Judie Stevens. As a result of todays inspection, deficiencies have been cited, see 809-D. A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. LPA informed Site Supervisor, Judie Stevens, that this report dated 8/31/2022, documents one Type A citation, which shall be posted for 30 consecutive days as there was immediate risk to the health, safety, or personal rights of children in care. Also, LPA informed the Site Supervisor to provide a copy of this licensing report dated 8/31/2022 that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Cortney Nelson LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022 FACILITY NAME: POMEROY DISTRICT PRESCHOOL FACILITY NUMBER: 4344

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA), Cortney Nelson, met with staff member, Ruth Hernandez, who states that Site Supervisor, Judie Stevens, is out on an errand and will return soon. Upon arrival, LPA explained purpose of visit to Ruth, follow-up on incident that occurred on 8/25/2022 and interview staff. LPA toured inside and outside of the facility and conducted COVID risk assessment. While touring outside playground, Site Supervisor, Judie, arrived to the facility. Visit today is in response to an incident that occurred that was called into the San Jose Regional Office (SJRO) by Site Supervisor, Judie, to report that on 8/25/2022 around 11:35AM a child was forgotten in the classroom after washing hands when returning from the playground. In the report, it was noted that the child was alone for approximately 2-3 minutes before returning to the classroom where all other children and staff were present. Unusual Incident Report (LIC624) was received by the SJRO on 8/26/2022 and Site Supervisor states that she additionally notified the parent of the child involved in the incident of its occurrence. LPA conducted interviews with staff involved in the incident as well as the Site Supervisor. Site Supervisor states that the typical routine is for children to be split into two groups for hand washing as the facility has inclusion program and some children may require more individualized attention. Also, there is limited sink space in classroom 21, so the group utilizes 2 additional sinks located in classroom 34. Since the incident, follow-up training has been conducted with the staff involved as well as changes in the procedure for hand washing and ratio maintenance. During todays visit, LPA discussed with Site Supervisor strategies for safe ratio management of the children and ways to ensure similar situation does not occur again in the future. Judie states that moving forward, the same 3 children will always accompany a designated staff member to room 34 for hand washing. White boards have been posted to clearly identify the number of children and staff present during the day and Site Supervisor states that walkie talkies have been ordered for utilization too. SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Cortney Nelson LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022 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 FACILITY NAME: POMEROY DISTRICT PRESCHOOLFACILITY NUMBER: 434400480 VISIT DATE: 08/31/2022 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 32LPA obtained copy of children's roster and training document (conducted 8/26/2022) signed by teachers involved in the incident during todays inspection. LPA additionally requested personnel roster (LIC500), however Site Supervisor states that she has not been able to create one yet. LPA wrote down names of all staff involved in supervision at the preschool from each program (Paraeducators and Student Adapted Instruction-SAI) instead. During todays visit, LPA additionally became aware of new Site Supervisor at the facility who states that she started at the beginning of August 2022. The department has not been made aware of the new Site Supervisor and LPA requested that she submit all required documents for review. Exit interview conducted and report was reviewed with Site Supervisor, Judie Stevens. As a result of todays inspection, deficiencies have been cited, see 809-D. A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. LPA informed Site Supervisor, Judie Stevens, that this report dated 8/31/2022, documents one Type A citation, which shall be posted for 30 consecutive days as there was immediate risk to the health, safety, or personal rights of children in care. Also, LPA informed the Site Supervisor to provide a copy of this licensing report dated 8/31/2022 that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Cortney Nelson LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022 FACILITY NAME: POMEROY DISTRICT PRESCHOOL FACILITY NUMBER: 4344

Type A citation - immediate risk to health, safety, or personal rights

Type B citation - potential risk if not corrected