434411994-8-20-2019-07-CC-SYIP-BF8UX9-20190820155759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411994
Report Date: 08/20/2019
Date Signed: 08/20/2019 03:58:12 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:	SVCC-PACIFIC WEST CHRISTIAN ACADEMY PRE.		FACILITY NUMBER:	434411994
ADMINISTRATOR:	BREE KUYAT		FACILITY TYPE:	850
ADDRESS:	8095 KELTON DRIVE		TELEPHONE:	(408) 310-7910
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	44	CENSUS: 20	DATE:	08/20/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Tamara Stuck-Utzig		TIME COMPLETED:	04:05 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) Samantha Yip conducted an unannounced annual random inspection. LPA met with Director Tamara Stuck Utzig and explained the reason for the inspection. Present during the inspection were 20 children and 5 staff. The teacher children ratio was observed to be in compliance during today's inspection. The hours of operation are Monday through Friday 7AM to 6PM. LPA reviewed sign in/sign out sheet, which contains full signature of authorized representative. License, Parent’s Rights, and Emergency Disaster Plan were observed to be posted. LPA toured the inside and outside of the facility with Director. The facility was observed to be clean and sanitary. Disinfectants, cleaning supplies or other items that could be dangerous to children were observed to be stored inaccessible to the children in care. LPA reminded Director to ensure that all cleaning supplies, such as Clorax wipes, are placed out of reach of children in care. LPA observed there is sufficient amount of toys for the children in care. The furniture and the equipment, such as tables and chair were age-appropriate and in good condition; free of sharp or loose, or pointed parts. Restrooms for children’s use were observed to be safe, sanitary, and in functioning condition. Facility does have a waiver to use the women's restroom on the site. Storage containers for waste have tight fitted lids. LPA observed a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. Director stated that there are no weapons stored on the premise. ---------------------continues on 809 dated 08/20/2019 page 2---------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2019

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: SVCC-PACIFIC WEST CHRISTIAN ACADEMY PRE.	FACILITY NUMBER: 434411994
	VISIT DATE: 08/20/2019

NARRATIVE

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The outdoor activity area is fenced. The playground equipment outside were maintained in safe condition, free of sharp, loose or pointed parts. Areas around play structures were cushioned with resilient materials to absorbs falls. Shaded rest areas are provided through building overhang and canopy. LPA did not observe any bodies of water.

All meals and snacks are prepared and brought from home. Drinking water is provided through individual water bottles.

Facility roster was reviewed and was copy was obtained. 10 children’s files were reviewed during today’s inspection. The records reviewed include but not limited to parent's rights and admission agreement.

5 staff files were also reviewed during today's inspection. The records reviewed include but not limited to immunization (Measles, Pertussis, and Influenza), education credit, and Mandated Reporter Training (AB 1207). There is currently at least one staff on site with valid CPR/First Aid, which expires 07/26/2021. LPA discussed Senate Bill 792 (immunization records for pertussis, measles, and flu vaccines), which began in 2016 for anyone working with the children and Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years. Mandated Reported Training can be accessed at http://www.mandatedreporterca.com.

Staff present during the inspection have cleared criminal record and child abuse index clearance. LPA also reminded 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.

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SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2019

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: SVCC-PACIFIC WEST CHRISTIAN ACADEMY PRE.	FACILITY NUMBER: 434411994
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/06/2019 Section Cited CCR 101226(e)(3)	1 2 3 4 5 6 7	Health-Related Services. Prescription medications may be administered if all of the following conditions are met: Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician. For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child. This requirement is not met as evident by:	1 2 3 4 5 6 7	By POC 09/06/2019, Director stated that she will obtain original packaging and concent from C-1's parents. Director will send proof to Licensing office.
	8 9 10 11 12 13 14	Based on observation and record review, LPA observed that C-1's medication was not in its original packaging, nor did the facility have consent from child's parent to administer the medication. This poses a potential risk to the health and safety to the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		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) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2019

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: SVCC-PACIFIC WEST CHRISTIAN ACADEMY PRE.	FACILITY NUMBER: 434411994
	VISIT DATE: 08/20/2019

NARRATIVE

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Director stated that she currently does children in care who requires Incidental Medical Services (IMS) services. Medication is properly stored where it is out of the reach of children. LPA observed that C-1's medication was not in its original packaging nor do they have a parent's consent to administer C-1's medication. Director stated that she will obtained packaging for C-1's medication and obtain parent consent. For IMS information, see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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.

LPA provided Director with Lead Exposure pamphlet. Director is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online Licensing Forms, Adoption of new Laws, etc.

In the areas evaluated during today's inspection, a Type B citation has been cited.. An exit interview was conducted, where this report, the citation, plan of correction, and appeal rights were discussed with Director Tamara Stuck-Utzig.

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

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2019

LIC809 (FAS) - (06/04)

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