013418186-5-25-2022-52-CC-RHAR-CES24J-20220525170401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013418186
Report Date: 05/25/2022
Date Signed: 05/25/2022 05:04:12 PM

Document Has Been Signed on 05/25/2022 05:04 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:	PRINCE OF PEACE PRESCHOOL		FACILITY NUMBER:	013418186
ADMINISTRATOR:	REGINA IMLACH		FACILITY TYPE:	850
ADDRESS:	38451 FREMONT BLVD.		TELEPHONE:	(510) 456-4280
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	76	CENSUS: 55	DATE:	05/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Regina Imlach		TIME COMPLETED:	05:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On May 25, 2022 at approximately 12:30 pm Licensing Program Analyst (LPA) Russ Haderer arrived to conduct an unannounced site inspection for health and safety. The new CARE tool was used for the inspection. LPA met with facility director, Regina Imlach and toured all areas licensed for use by children in care. Also present at the time of this inspection were 10 teaching staff and 55 children in care (all preschool age). The facility is within ratio and capacity. The hours of operation remain 7:00am to 6:00pm. The facility is located on the church property on the south side in the back of the campus. The facility consists of 4 classrooms with private playground space for the children on the south side. The playground is surrounded by a 6-foot privacy fence, secured with gates with inside latches too high for children to reach. 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. Shade was available in the play areas and teachers are always present. A water fountain is available, however, due to covid, it is currently not in use. Children are bringing in their own bottled water from home. Drinking water is also available and provided by staff with a water cart indoors and outdoors. The facility is clean and well organized with age appropriate furnishings and equipment in good repair. Surfaces including floors and counter tops are clean and toxic free. There are ample age-appropriate toys that appear to be safe and in good condition. There are no bodies of water accessible to children in care. There were no hazardous items/toxins observed to be accessible to children in care today. Each classroom has a 3A40BC fire extinguisher, fully charged with the last annual inspection done in September 24, 2021. There are working carbon monoxide detectors (tested and working) and fire alarms mounted on the high ceilings. The fire alarm system is tested annually, the last test was completed on 2/11/2022 by Three Alarm Fire Protection. All systems passed inspection.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell Haderer	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

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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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: PRINCE OF PEACE PRESCHOOL	FACILITY NUMBER: 013418186
	VISIT DATE: 05/25/2022

NARRATIVE

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Plastic safety covers were present on electrical outlets, heating and ventilation was acceptable. Disaster drills are conducted at least once every six months, the last drill was conducted on 4/04/2022.

There is an off-limits kitchen consisting of a refrigerator, washer/dryer laundry unit, purified water dispenser, a sink with hot and cold running water and a trash bin with a cover and a recycle bin. Currently the school does not provide lunch or snacks (due to Covid), parents supply all food. The school has an adequate supply of snacks on hand if needed. All snacks for children were checked and none were out of expiration.

There are 3 children’s bathrooms and one staff bathroom. The sinks have functioning cold water taps with appropriate hand washing signs. There are touch-free trash cans with lids and sufficient amounts of towels, soap and diaper supplies. All toilets, hand washing and cleaning areas are in safe and sanitary operating condition. Classrooms have touchless trash cans with tight fitting cover for the disposal of solid waste.

The sign in/out sheets are electronic and were reviewed. All children present were signed in. The sign in/out system stores information for a minimum of 30 days and reviewed. A backup system is available (traditional pen and paper sign-in/sign-out) .

The center administers medication (EpiPens, inhalers and antihistamines for allergies). Medication is stored in the administration office (and in the emergency disaster bags). All medications were checked and are not expired. Incidental Medical Services Plan is on file.

The children's napping areas are clean and organized with sleeping pads and cubbies for the children's personal items, none of the children's blankets were touching.

All documents required to be posted were present. - There is a waiver for rotating the children in the play area, waiver is also posted.

At approximately 2:55 pm LPA performed children's record reviewed: LPA requested and reviewed facility roster, a copy was taken. Two children’s files were missing the required signed LIC613A Personal Rights forms. See LIC809D for deficiency All other files selected were complete and up to date and found to be in compliance with Title 22 regulations.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell Haderer	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: PRINCE OF PEACE PRESCHOOL	FACILITY NUMBER: 013418186
	VISIT DATE: 05/25/2022

NARRATIVE

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At approximately 4:00 pm LPA performed staff file review. All staff subjected to criminal review have been cleared and associated to the facility. All files were complete, up to date and found to be in compliance with Title 22 regulations.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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

All adults present are background cleared and associated to this facility. Center 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.

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 was one deficiency found during today’s inspection, see LIC809D. This report will remain on file for three 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, Regina Imlach.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell Haderer	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/25/2022 05:04 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: PRINCE OF PEACE PRESCHOOL	FACILITY NUMBER: 013418186
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101223(b)(1)

Personal Rights

(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that two children's files were missing the signed LIC613A Personal Rights forms from their parent or authorized representatives which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2022
	Plan of Correction
1 2 3 4	Center Director will collect the signed form for the two children's files and submit photos as proof of completion to LPA. An inventory of all other children's files will be made to ensure no other forms are missing and going forward a thorough checklist will be followed so all children's files are complete.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell Haderer	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

LIC809 (FAS) - (06/04)

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