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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701997
Report Date: 12/07/2022
Date Signed: 12/07/2022 04:27:51 PM

Document Has Been Signed on 12/07/2022 04:27 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ST. TIMOTHY'S CHRISTIAN PRESCHOOLFACILITY NUMBER:
430701997
ADMINISTRATOR:JEANETTE ADAMSFACILITY TYPE:
850
ADDRESS:5100 CAMDEN AVENUETELEPHONE:
(408) 265-0244
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 85TOTAL ENROLLED CHILDREN: 56CENSUS: 11DATE:
12/07/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Shawnese LaffodayTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA), James Santos arrived at the facility today to conduct the continuation of the Annual inspection. LPA met with Assistant Director, Shawnese Laffoday.

During today/s inspection, LPA reviewed records. LPA reviewed ten (10) children's records which include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, Medical Assessment and Immunization. LPA reviewed five (5) staff records. Staff records reviewed include Criminal Record Clearance, Immunization Record, CPR/First Aid, Mandated Reported Training and Qualifications.

Incidental Medical Services (IMS) policy was discussed and reviewed. 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.

Assistant 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.


No deficiencies cited. Exit interview conducted. Report was reviewed and a copy was provided to Assistant Director, Shawnese Laffoday.


NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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