<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400411
Report Date: 07/08/2022
Date Signed: 07/08/2022 04:16:12 PM


Document Has Been Signed on 07/08/2022 04:16 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:FOOTHILL CHRISTIAN PRESCHOOL & DAYCAREFACILITY NUMBER:
434400411
ADMINISTRATOR:KRISTINA MUSGRAVEFACILITY TYPE:
850
ADDRESS:5301 MCKEE ROADTELEPHONE:
(408) 258-2171
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:60CENSUS: DATE:
07/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Kristina MusgraveTIME COMPLETED:
04:30 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 Analyst (LPA) Janette Cruz, conducted a case management visit and met with Kristina Musgrave, Director. LPA observed six staff (Director, 4 teachers and 1 teacher aide) and 15 children.

A complaint was submitted to Licensing and by the information gathered through the investigation, LPA concludes that facility violated regulations on Reporting Requirements and Personal Rights (Lack of Supervision). An Unusual Incident Report regarding a head injury of a child that occurred on 4/19/22 was submitted to Licensing on 5/11/22. LPA also notes that a child sustained the unexplainable injuries bite/bruise marks on the arm and leg not witnessed by staff how and when the injuries happened while under their care.

Based on the available information, deficiencies are being cited. See 809-D page.

Exit interview was conducted and appeal rights were provided to Kristina Musgrave, Director.

A Notice of Site Visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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 2


Document Has Been Signed on 07/08/2022 04:16 PM - 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: FOOTHILL CHRISTIAN PRESCHOOL & DAYCARE
FACILITY NUMBER: 434400411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited

1
2
3
4
5
6
7
Reporting Requirements (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
(1) Events reported shall include the following:
(c) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.

This requirement was not met as evidenced by:

8
9
10
11
12
13
14
Based on record reviews and interviews, the Licensee did not comply with the section cited above. Licensee was not able to meet timely submission of the Unusual Incident Report regarding a child head injury that occurred on 4/19/22 which posed a potential health, safety or personal rights risk to persons in care.

8
9
10
11
12
13
14
Type B
07/15/2022
Section Cited

1
2
3
4
5
6
7
Care and Supervision. No child(ren) shall be left without the supervision, including visual
observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and
101230(c)(1). This requirement was not met as evidenced by:

8
9
10
11
12
13
14
Based on observation, interviews and record reviews, Licensee did not comply with the
section cited above. A child sustained unexplainable injuries of two bite/bruise marks on his arm and leg not witnessed by staff how and when the injuries
happened while child was under their care which posed
potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2