434400287-9-26-2019-07-CC-MMOO-BGDSKK-20190926135652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434400287
Report Date: 09/25/2019
Date Signed: 09/26/2019 01:57:02 PM

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:	GOOD SAMARITAN ED. & ENRICHMENT PROGRAMS		FACILITY NUMBER:	434400287
ADMINISTRATOR:	WONG, LORETTA		FACILITY TYPE:	830
ADDRESS:	19624 HOMESTEAD ROAD		TELEPHONE:	(408) 996-8290
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	24	CENSUS: 18	DATE:	09/25/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Stacy O'Toole		TIME COMPLETED:	03:25 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 Analysts (LPAs), Marilou Monico, Nancy Rodriguez, and Araceli Almaraz, met with Assistant Director, Stacy O'Toole, for an unannounced annual random inspection. The infant program is operating in Rooms 10, 14, and 15. LPAs observed all required posted materials: License, Parents' Rights, Emergency Disaster Plan, menus, Earthquake Preparedness Checklist, Child Passenger Safety Law, and activity schedule. The preschool program's days and hours of operation are Monday to Friday from 7:00 AM to 6:00 PM. LPAs inspected the building both indoor and outdoor. LPAs observed that the facility was operating in compliance with teacher to children ratio requirement. Children were engaged in activities under the supervision of the teachers. LPAs observed trash cans with tight fitting covers throughout the facility. Diapers are being disposed appropriately. Bottles, sippy cups, and foods brought from home are labeled. LPAs observed child's used bedding is touching other bedding in Room 14. There is a functioning carbon monoxide detector at the facility. LPAs did not observe any bodies of water. LPAs reviewed 10 random children's files and one staff file. The Infant Needs and Services Plan for each infant is updated quarterly. At least one staff member present during the inspection has current CPR/First Aid certifications. Per Assistant Director, there are no weapons on the premise. Outdoor activity space is enclosed by fencing. Shade is provided by trees and canopies. The areas around climbing equipment have resilient material to absorb falls. Drinking water is readily available to children indoor and outdoor via individual water bottles and sippy cups. Parents provides snacks and meals for children in Rooms 10 and 14. The facility provides snacks to children in Rooms 15. There is a kitchen at the facility for food preparation. The kitchen is equipped with refrigerator, microwave, and sink with hot and cold running water. Sanitation is by hand washing. LPAs observed that food storage areas were clean, free of litter, and rodents. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 09/25/19):

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2019

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: GOOD SAMARITAN ED. & ENRICHMENT PROGRAMS	FACILITY NUMBER: 434400287
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/26/2019 Section Cited	1 2 3 4 5 6 7	CRIMINAL RECORD CLEARANCE - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility Request a transfer of a criminal record clearance as specified in Section 101170(f).
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Yanying (Lisa) Qin has fingerprint clearance but not associated to the facility. This poses an immediate risk to the health and safety to children in care. Civil penalty of $500.00 was assessed during the inspection.	8 9 10 11 12 13 14	Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.
	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: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2019

LIC809 (FAS) - (06/04)

Page: 4 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: GOOD SAMARITAN ED. & ENRICHMENT PROGRAMS	FACILITY NUMBER: 434400287
	VISIT DATE: 09/25/2019

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
26
27
28
29
30
31
32

CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 09/25/19):

A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions with the exception of Yanying(Lisa) Qin. Yanying has fingerprint clearance but not associated to the facility. LPAs also reminded Assistant Director of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

LPAs discussed Senate Bill 792, AB 633, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years with Assistant Director. Licensing forms, Title 22 regulations, can be obtained through the internet at ww.ccld.ca.gov. Mandated Reporter Training can be accessed at www.mandatedreporterca.com.

Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPAs provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility.

As a result of this inspection, deficiencies were cited on the following pages:

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2019

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: GOOD SAMARITAN ED. & ENRICHMENT PROGRAMS	FACILITY NUMBER: 434400287
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/09/2019 Section Cited	1 2 3 4 5 6 7	Napping Equipment - Bedding shall be individually stored so that each child's bedding is identifiable and no child's used bedding comes into contact with other bedding. This requirement is not met as evidenced by: LPAs observed child's used beddings is touching other bedding. This poses a potential risk to the health and safety to children in care.
	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: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2019

LIC809 (FAS) - (06/04)

Page: 3 of 4