073400100-5-16-2023-02-CC-ACUY-CRVPP4-20230516112855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073400100
Report Date: 05/16/2023
Date Signed: 05/16/2023 11:29:05 AM

Document Has Been Signed on 05/16/2023 11:29 AM - 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:	HOLY SHEPHERD CHRISTIAN PRESCHOOL		FACILITY NUMBER:	073400100
ADMINISTRATOR:	KOEPER, SUSAN		FACILITY TYPE:	850
ADDRESS:	433 MORAGA WAY		TELEPHONE:	(925) 254-3429
CITY:	ORINDA	STATE: CA	ZIP CODE:	94563
CAPACITY:	25	CENSUS: 5	DATE:	05/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Pastor Valentine/Amy Cabiles		TIME COMPLETED:	12:00 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 05/16/2023 at 9:30 AM Licensing Program Analyst (LPA), A. Curry conducted an unannounced random inspection. LPA met with teacher, Amy Cabiles. This is a preschool age program licensed for 25 children which operates Monday- Friday from 9:00 AM – 12:00 PM and Monday, Wednesday, and Friday 12:00PM- 2:00PM Per the lead teacher there are 17 children enrolled. LPA A. Curry began facility tour and all areas identified on the facility sketch were inspected. LPA observed 5 children with 1 staff. Teacher-child ratios were observed to be in accordance with Title 22 regulations. The Licensee is within the conditions, limitations, and capacity specified on the license. Staff name was recorded. All children were observed to be under visual supervision of a teacher at all times. LPA observed the facility to be clean, safe, sanitary and in good repair. Furniture and equipment was inspected for good repair, free of sharp, loose, or pointed parts. All indoor classrooms were inspected to ensure that the floors have a surface that is safe and clean. All toilets and hand washing facilities are in safe and sanitary operating conditions. All materials and surfaces accessible to children are toxic free. At this time, an area in the classroom away from other children is used as an isolation area. Parents are contacted immediately when children are determined to be ill and staff are ensuring that children with obvious symptoms of illness are not being accepted. Snack menus were reviewed. There is drinking water available in all indoor classrooms and individual drinking containers are taken outdoors. All storage containers for solid waste, including moveable bins, have tight fitting covers on and are in good repair. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are stored in an area inaccessible to children. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. The licensee takes measures to keep the facility free of flies, other insects and rodents.

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley Curry	TELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HOLY SHEPHERD CHRISTIAN PRESCHOOL	FACILITY NUMBER: 073400100
	VISIT DATE: 05/16/2023

NARRATIVE

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Outdoor play equipment was observed to be in good condition, free of sharp, loose or pointed parts. Outdoor activity space surface is maintained in a safe condition and is free of hazards. Areas around and/or under climbing equipment, swings and slides have cushioning material to absorb a fall. LPA did not observe any bodies of water during this visit. Lead teacher states there are no weapons or firearms on the premises.

Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. Staff Records were reviewed to ensure that a health screening report and immunization records are on file. Staff did not have immunization records in file (See 809D). Staff indicated she has another file in a locked office, that could not be accessed during the visit. Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. Criminal Records Clearance for adults and verification of CPR/First Aid and health preventative practices documentation was reviewed.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

Licensee 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/process.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted, appeal rights were given, and report was reviewed with the lead teacher Amy Cabiles.

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley Curry	TELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2023 11:29 AM - 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: HOLY SHEPHERD CHRISTIAN PRESCHOOL	FACILITY NUMBER: 073400100
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by ensuring immunizations are in staff's file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/16/2023
	Plan of Correction
1 2 3 4	By 06/16/2023 submit proof of immunity for measles, pertussis, and tuberculosis.

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: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley Curry	TELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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