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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430702694
Report Date: 01/31/2023
Date Signed: 01/31/2023 02:30:58 PM


Document Has Been Signed on 01/31/2023 02:30 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:SHEPHERD OF THE VALLEY LUTHERAN CHURCHFACILITY NUMBER:
430702694
ADMINISTRATOR:TANIA KENNEDYFACILITY TYPE:
850
ADDRESS:1281 REDMOND AVENUETELEPHONE:
(408) 997-4846
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY:75CENSUS: 32DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Tania KennedyTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Janette Cruz met with Tania Kennedy, Director, for an unannounced Required- 1 Year inspection. LPA toured the indoor and outdoor areas of the facility during today's inspection. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), and Activity Schedule. Days and hours of operations are Monday through Friday 7:30 AM to 4:00 PM.

LPA reviewed children's files and staff files (director, four teachers) during today's inspection. Each child's file reviewed contains the Information and Emergency Information form (LIC 700) and all required licensing forms. All staff files reviewed contain the required transcripts/verification of experience/immunization records, and Health Screening Report. LPA reviewed current certificates of completion of the Mandated Reporter Training for Child Care Workers and current CPR and First Aid certifications for staff on file. Director understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during outdoor activities. Sign in and sign out sheets are in compliance.



LPA observed that the teacher/child ratio was in compliance during today's inspection. Present during the inspection were 32 preschool children and 11 staff. Director understands the conditions, limitations, and capacity specifications of the Facility license. Director understands that children shall be visually supervised at all times. Any child(ren) who exhibit symptoms of illness including, but not limited to, fever or vomiting, are not accepted in care. Any child(ren) who become ill during the day, shall be isolated in the facility's office.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SHEPHERD OF THE VALLEY LUTHERAN CHURCH
FACILITY NUMBER: 430702694
VISIT DATE: 01/31/2023
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LPA observed that the Facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. Director understands that the facility must be kept free of insects & rodents. LPA observed that all furniture and equipment are in good condition and safe for the children. Drinking water is readily available for the children in the facility and in the outdoor playground area via water fountain and water bottles labeled with each child's name. Staff and children's bathrooms are clean, sanitary, and in working order. Director states that there are no weapons or firearms on the premises. The Facility has functioning carbon monoxide detectors indoors.

The food preparation and storage areas are clean, free of litter & rubbish, free of rodents and other vermin. There is also a hot and cold running water, refrigerator and microwave on the premises. Lunch is prepared and brought from home. The facility provides snacks to the children in care. Menu was posted. The kitchen used to prepare snacks was observed to be clean and sanitary. The Facility has trash cans with tight fitting lids for solid waste in the classroom. Cleaning supplies are inaccessible to the children and stored in locked and/or high cabinets LPA observed a complete First Aid kit, including touch less thermometer, in the Facility.

The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. Shade rest areas are provided by trees and building overhang. There is sufficient resilient materials (woodchips) on the outdoor playground area. LPA observed a locked storage shed. LPA did not observe any bodies of water. Director states that the Facility does not provide transportation.

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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SHEPHERD OF THE VALLEY LUTHERAN CHURCH
FACILITY NUMBER: 430702694
VISIT DATE: 01/31/2023
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This facility is currently not providing Incidental Medical Services (IMS). 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

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

Exit interview conducted and report was reviewed with Director, Tania Kennedy. No deficiency was cited during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC809 (FAS) - (06/04)
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