<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070213244
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:40:16 PM


Document Has Been Signed on 04/27/2023 02:40 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, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:CALVARY CHRISTIAN SCHOOLFACILITY NUMBER:
070213244
ADMINISTRATOR:MULLENS, AMYFACILITY TYPE:
850
ADDRESS:3425 CONCORD BLVD.TELEPHONE:
(925) 682-6728
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:82CENSUS: 42DATE:
04/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:AMY MULLENSTIME COMPLETED:
02:45 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
LICENSING PROGRAM ANALYST MET TODAY WITH CENTER DIRECTOR AMY MULLENS TO DISCUSS A SELF REPORTED UNUSUAL INCIDENT THAT OCCURRED ON 4/14/23 WHEN A CHILD WAS ABLE TO WALK OUT OF HIS/HER CLASS ROOM WITHOUT STAFF'S KNOWLEDGE.

UPON ARRIVAL THERE ARE 42 PRESCHOOL AGE CHILDREN PRESENT ALONG WITH 3 STAFF INCLUDING THE DIRECTOR.. TODAY AN INTERVIEW WAS CONDUCTED WITH MRS. MULLENS WHO SAYS THE CHILD WALKED OUT OF THE CLASS ROOM AND OUT OF THE BUILDING WHILE THEIR TEACHER WAS CHANGING ANOTHER CHILD'S DIAPER. STAFF ATTEMPTED TO LOOK FOR THE CHILD FOR APPROXIMATELY 15 MINUTES BEFORE THE CHILD WAS BROUGHT BACK INTO THE FACILITY BY A BYSTANDER.

DIRECTOR SAYS THE FACILITY HAS SINCE INSTALLED ALARMS ON ALL DOORS TO PREVENT FUTURE INCIDENTS LIKE THIS FROM HAPPENING. THE CHANGING TABLE IN THE CLASS ROOM HAS BEEN REPOSITIONED SO STAFF CAN SEE THE ENTIRE ROOM AT ALL TIMES AND DAY CARE PARENTS WERE NOTIFIED OF THE INCIDENT BY LETTER. A MEETING WAS ALSO HELD WITH THE CHILD'S PARENTS.

THE ACKNOWLEDGMENT OF RECEIPT OF LICENSING REPORTS HAS BEEN GIVEN AND EXPLAINED. A COPY OF THIS REPORT IS TO BE GIVEN TO EACH DAY CARE CHILD'S PARENT OR GUARDIAN BY THE NEXT BUSINESS DAY AND THE SIGNED ACKNOWLEDGMENT FORM MUST BE PUT INTO THEIR CHILD'S FILE.. A COPY OF THIS REPORT WILL ALSO BE GIVEN TO ANY NEWLY ENROLLED CHILD'S PARENT OR GUARDIAN FOR UP TO ONE YEAR. THIS REPORT MUST BE POSTED AT THE FACILITY FOR 30 DAYS

PLEASE SEE 809-D FOR CITATION AN EXIT INTERVIEW WAS CONDUCTED AND A NOTICE OF SITE VISIT WAS POSTED.



SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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


Document Has Been Signed on 04/27/2023 02:40 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, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: CALVARY CHRISTIAN SCHOOL
FACILITY NUMBER: 070213244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited

1
2
3
4
5
6
7
101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.

(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
1
2
3
4
5
6
7
THE FACILITY HAS SINCE INSTALLED ALARMS ON ALL DOORS OF THE FACILITY, REPOSITIONED THE CHANGING TABLE IN THE CLASS ROOM SO STAFF IS ABLE TO OBSERVE THE ENTIRE ROOM WHILE CHANGING DIAPERS, NOTIFIED DAY CARE PARENTS OF THE INCIDENT VIA
8
9
10
11
12
13
14
THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY INTERVIEWS AND OBSERVATION WHICH REVEALED A CHILD WAS ABLE TO WALK OUT OF THE CLASS ROOM AND BUILDING WHILE THE TEACHER'S BACK WAS TURNED WHILE CHANGING ANOTHER CHLD'S DIAPER.
8
9
10
11
12
13
14
LETTER AND HELD A MEETING WITH THE CHILD'S PARENTS. LICENSEE WILL ALSO HAVE AN ALL STAFF TRAINING ON CHILD SUPERVISION. LICENSEE WILL SUBMIT TO COMMUNITY CARE LICENSING A WRITTEN PLAN OF ACTION AND A LIST/SIGN IN SHEET OF ALL STAFF WHO ATTEND THE TRAINING BY
5/11/2023.





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
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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2