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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416767
Report Date: 05/06/2022
Date Signed: 05/06/2022 02:32:24 PM


Document Has Been Signed on 05/06/2022 02:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:HARVEST CHRISTIAN PRESCHOOL/DAYCAREFACILITY NUMBER:
013416767
ADMINISTRATOR:DISLA DE PEREZ, JUANAFACILITY TYPE:
850
ADDRESS:4360 HANSEN AVENUETELEPHONE:
(510) 713-8748
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:98CENSUS: 22DATE:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Juana PerezTIME COMPLETED:
02:45 PM
NARRATIVE
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On May 6, 2022 at approximately 8:50am, LPA Haderer arrived unannounced for an annual inspection for compliance to Health and Safety. The new CARE tool was used for the inspection. Present for the inspection was the Center Director Juana Perez, 4 teachers; 22 children in care (all preschool age). The facility is in ratio today. The hours are 8:00 am to 5:00pm.

The facility has 5 classrooms (2 are not in use at this time), a small kitchen/food prep area; 2 children’s bathrooms; a Chapel, and outside playground area surrounded by a 6-foot chain link fence. There are sturdy play structures, LPA observed that all play equipment is in safe condition and free from sharp, loose or pointed parts and the areas around or under high climbing equipment has appropriate cushioned material that absorbs a fall. There is water available for the children and they also bring their own bottled water to school. Ample shade is available and teachers are always present when the children are outside.



Sign in/out sheets are available and checked to verify children present were signed in. Classrooms have trash cans with tight fitting covers for the disposal of solid waste. Each classroom have functioning cold-water sinks with adequate soap and paper towels. At this time the facility does not have any children that need incidental medical services.

Children’s bathrooms are available and contain enough towels and soap supplies. The staff have a separate adult stall not used by the children. Fire and Earthquake disaster drills are conducted monthly, the last drill was conducted 4/06/2022.

The facility has fully charged 3A40BC fire extinguishers throughout the hallways and classrooms. The last annual inspection was done 5/21/2021. Johnson Controls Inc. conducts the fire systems inspections, the last inspection was completed on 10/19/2021 and all smoke detectors and the fire system are in good working order and passed inspection. Carbon monoxide detectors were present, tested and functioning. Heating and ventilation in the classroom is acceptable.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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Document Has Been Signed on 05/06/2022 02:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: HARVEST CHRISTIAN PRESCHOOL/DAYCARE
FACILITY NUMBER: 013416767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101170(d)
Criminal Record Clearance
(d) All individuals subject to criminal record review shall, be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one staff member's personnel file was missing the signed LIC508 Criminal Record Statement.which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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Licensee immeditaely had the staff member sign the LIC508 form and will keep it in the personnel file.
Type B
Section Cited
CCR
101216(l)(1)(B)
Personnel Requirements
(B) A copy of the signed LIC 9052 (11/94) shall be kept in the employee's personnel record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that two staff members files were missing the signed LIC9052 Employee Rights form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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Center Director immediatley had the forms signed and dated by the staff and placed the signed portions in the personnel file.

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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: HARVEST CHRISTIAN PRESCHOOL/DAYCARE
FACILITY NUMBER: 013416767
VISIT DATE: 05/06/2022
NARRATIVE
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The facility is clean and well organized with ample age appropriate furnishings and equipment. Surfaces including floors and counter tops are clean and toxic free. Hazardous items/toxins are kept out of the access of children. There are no bodies of water accessible to children in care. The facility provides snacks for the children, menus were appropriately posted throughout the facility. All dry good and canned foods were checked and not expired.

At 11:40am staff files were reviewed. Two staff members files did not contain the LIC9052 Employee Rights form and one file did not contain the signed LIC508 Criminal Record Statement. See LIC809D for the deficiency. All other files were complete and in good order.

Children’s files were reviewed. One child’s file was missing the signed receipt of form LIC 995 Parent’s Rights. See LIC809D for the deficiency. All other files were complete and in good order.

All documents required to be posted were appropriately posted on the walls: License (and playground waiver underneath); Emergency Disaster Plan; Earthquake Preparedness checklist; Notification of Parents Rights; Personal rights; Child seatbelt laws; menus; daily activity schedules.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing 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

Site Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: HARVEST CHRISTIAN PRESCHOOL/DAYCARE
FACILITY NUMBER: 013416767
VISIT DATE: 05/06/2022
NARRATIVE
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

There were three deficiencies issued today, see LIC809D. This report will remain on file for 3 years.

A notice of site visit was given and must remain posted for 30 days.



Exit interview conducted and report was reviewed with the Center Director Juana Perez.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/06/2022 02:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: HARVEST CHRISTIAN PRESCHOOL/DAYCARE
FACILITY NUMBER: 013416767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101218(e)(1)
101218.1 Admission Procedures and Parental and Authorized Representative's Rights
(e)(1) … The bottom portion of this form must be kept in the child's file as proof that the parent or authorized representative has been notified of his or her rights by the child care center and received a copy of the LIC 995E, Caregiver Background Check Process form.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one child's file did not contain the signed LIC995 Parent's Rights form in the file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Center Director will have a parent of the child sign and date the LIC995 form and place it in the child's file. Center Director will also review all children's files to ensure they are not missing any required documentation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5