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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710384
Report Date: 02/05/2020
Date Signed: 02/05/2020 11:24:15 AM

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:CALVARY CHAPEL CHRISTIAN SCHOOLFACILITY NUMBER:
430710384
ADMINISTRATOR:MELINDA TIOPANFACILITY TYPE:
850
ADDRESS:1175 HILLSDALE AVENUETELEPHONE:
(408) 269-2222
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:90CENSUS: 32DATE:
02/05/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Melinda TiopanTIME COMPLETED:
11:30 AM
NARRATIVE
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LPA, Behbood made a visit to conduct an annual/Random visit. Met Melinda Tiopan. Present also were 32 children and 4 staff. The purpose of the visit explained. Inside and play ground was toured. Random Staff and children files were reviewed. Operation hours: Monday through Friday from 7:30 to 5:30 from late August to beginning of June.
All staff have clearances on Licensing system. Ms. Tiopan understands that all staff must have a clearance associated to the facility before they can be present. Failure to do so will result in a fine.
There are no bodies of water at the facility. Ms. Tiopan states there are no weapons at the Preschool.
Cleaning supplies are stored in the kitchen cabinets inaccessible to children. Furniture & equipment appear in good condition. Floors appear clean. Children's bathrooms are in operating condition. Children bring their lunch from home, facility serve AM and PM snacks, there is a main kitchen and then mini kitchens in the classrooms. Food are covered in the refrigerator. Trash can for food waste has a tight fitting cover. Menu is posted. Fire, earth quake and lock down drills are conducted monthly and it is documented. Playground has climbing structures, sand boxes, etc., and canopy for shades. Wood chips are used for cushioning material. There is gym that children use during the rainy days. Drinking water inside and outside the classrooms are provided via pitchers and cups . Staff have current CPR & 1st aid cards. Staff files have copies of their educational background and proof of immunization. Children's files have emergency information. Children were supervised during the visit. Teacher/child ratio was met during the visit.

Please see next page for citation under Title 22.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2020
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 4
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: CALVARY CHAPEL CHRISTIAN SCHOOL
FACILITY NUMBER: 430710384
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2020
Section Cited

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Responsibility for Providing Care and Supervision-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.
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This requirement has not been met evidence by: observed during visit, children use bathroom in the classroom with door closed, no visual supervision observed. This is potentially harmful to health and safety of children.
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Type B
02/07/2020
Section Cited

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Health Related Services-When no longer needed by the child, or when the child withdraws from the center, all medications shall be returned to the child's authorized representative or disposed of after an attempt to reach the authorized representative.
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This requirement has not been met evidence by: Medication for 2 children that no longer attend the center observed to be in medication box.
This is potentially harmful to health and safety of children.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: CALVARY CHAPEL CHRISTIAN SCHOOL
FACILITY NUMBER: 430710384
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2020
Section Cited

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Sign In and Sign Out - The person who brings the child to, and removes the child from, the center shall sign the child in/out.This requirement has not been met evidence by:
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At least 3 children were not signed in in 2 different classroom. This requirement has not been met evidence by: At least 3 children were not signed in in 2 different classrooms.
This is potentially harmful to health and safety of children.
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Type B
02/07/2020
Section Cited

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IMMUNIZATION SB792 -
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. enza vaccines.
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This requirement has not been met evidence by: One staff doesn't have proof of immunization in her file, she has been employed for one year now.
This is potentially harmful to health and safety of children.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: CALVARY CHAPEL CHRISTIAN SCHOOL
FACILITY NUMBER: 430710384
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2020
Section Cited

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Outdoor Activity - As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls.
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This requirement has not been met evidence by: Tan barks under the climbing structure are low in quantity and compacted. This is potentially harmful to health and safety of children.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4