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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
434411994
Report Date:
08/26/2022
Date Signed:
08/29/2022 08:22:49 AM
Document Has Been Signed on
08/29/2022 08:22 AM
- 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:
SVCC-PACIFIC WEST CHRISTIAN ACADEMY PRE.
FACILITY NUMBER:
434411994
ADMINISTRATOR:
STEPHANIE GAMBLE
FACILITY TYPE:
850
ADDRESS:
8095 KELTON DRIVE
TELEPHONE:
(408) 310-7910
CITY:
GILROY
STATE:
CA
ZIP CODE:
95020
CAPACITY:
44
CENSUS:
29
DATE:
08/26/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:53 AM
MET WITH:
Catrina Kalesh
TIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 1 Year inspection. LPA met with Catrina Kalesh, Director, and explained the reason for the inspection. Present during today's inspection were 29 children and at least 5 staff.
There is board to post to required postings, such as license, personal right's parent's rights, car seat law. There is working phone at the center. LPA reviewed sign in-out sheet. LPA observed that were only 15 children signed in. LPA discussed with Catrina about ensuring that all children are signed in and out with the date and time.
LPA toured the inside and outside with Director. LPA observed that there were containers of disinfectant wipes and bottles of hand sanitizers that were in an unlocked cabinet or on a shelf that was accessible to children. LPA discussed with Director about ensuring disinfectant wipes and hand sanitizers need to be out of reach of children. Toys and equipment were observed to be age appropriate. Bathroom for children were observed to be clean. Facility has a waiver to use one stall and one sink in the bathroom next to the lobby. LPA observed that facility was using the men's and women's restroom next to the lobby. LPA discussed with Director about submitting an updated waiver request to use both bathrooms. There is fully charged fire extinguisher, smoke detector, and carbon monoxide detector. Director stated that there are no weapons, such as firearms, stored on the premise.
------------------continues on 809 dated 08/26/2022 page 2------------------------
SUPERVISOR'S NAME:
Joel Segura
TELEPHONE:
(408) 334-8550
LICENSING EVALUATOR NAME:
Samantha Yip
TELEPHONE:
(408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE:
08/26/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/26/2022
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:
08/26/2022
NARRATIVE
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------------------continuation of 809 dated 08/26/2022 page 1--------------------
The outdoor activity area is fenced. Area around play structure have resilient material. Shaded rest area is provided through tree and building overhang. Director stated that the facility currently only serves children 3 years old to 1st. LPA discussed with Director about supervision on the playset area. LPA also discussed with Director that the playstructure on playset area is for children 3 years old to 12 years old. Director stated that children 3 to 4 years old use the play area. There was no bodies of water observed during today's inspection.
All meals and snacks are prepared and brought from home. Drinking water is provided through individual water bottles and drinking fountain. Trash can for waste have tight-fitted lids.
Facility does provide Incidental Medical Services.
LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. LPA observed that C-1's epi-pen expired on 01/2022. Director stated that she requested a epi-pen from C-1. LPA also observed that there bottles of Benadryl that were expires; one bottle expired on 05/2022 and the other expired o
n 02/2022. For IMS information, see
PIN 22-02-CCP
. A 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
A copy of the facility roster was obtained during today's inspection. 10 children's file's review were reviewed during today inspection. The records reviewed include, but not limited to admission agreement, personal's rights. LPA discussed with Director about checking that all children's files are complete. A list of items that were missing in children's file was provided to Director.
-------------------continues on 809 dated 08/26/2022 page 3-----------------------
SUPERVISOR'S NAME:
Joel Segura
TELEPHONE:
(408) 334-8550
LICENSING EVALUATOR NAME:
Samantha Yip
TELEPHONE:
(408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE:
08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/26/2022
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:
08/26/2022
NARRATIVE
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----------------continuation of 809 dated 08/26/2022 page 2--------------------
Four staff files were reviewed during today's inspection. The records reviewed include but not limited to education credit, Mandated Reporter training, and immunization records. There are two staff who completed the CPR/1st Aid training on 01/2021 through American Health Care Academy, which is online. There is no EMSA sticker on card. LPA discussed with Director that CPR/1st Aid needs to be completed through American Heart Association, American Red Cross, or a program that is EMSA approved and cannot be completed online. Director stated that she will register for CPR/1st Aid training and send proof to Licensing by 09/09/2022. LPA observed that S-3 and S-4 did not have immunization records for measles, pertussis, and influenza on file. S-1 and S-2 did not have file on site. LPA discussed with Director about having files on site. LPA reminded Director that Mandated Reporter training requires renewal every two years. S-4 completed the General Mandated Reporter training. Director will send proof of Child Care Provider Mandated Reporter training to Licensing. LPA discussed with Director about having a copy of required Licensing forms on site.
LPA was notified of change to director on 08/25/2021 and requested documents to be submitted to Licensing. LPA reviewed director's file during today's inspection. Director stated that she completed the admin/supervision course and is waiting for her transcript to come in.
Director will submit all required forms and documents for director to Licensing by 09/09/2022.
LPA provided Director with LIC 311A: Records to be Maintained at Facility: Child Care Center and LIC 9040: Facility Roster during today's inspection.
------------------continues on 809 dated 08/26/2022 page 4------------------------
SUPERVISOR'S NAME:
Joel Segura
TELEPHONE:
(408) 334-8550
LICENSING EVALUATOR NAME:
Samantha Yip
TELEPHONE:
(408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE:
08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/26/2022
LIC809
(FAS) - (06/04)
Page:
3
of
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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:
08/26/2022
NARRATIVE
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-------------------continuation of 809 dated 08/26/2022 page 3--------------------
During today's inspection, S-1 and S-2 were present at the facility and did not have cleared fingerprints. Both S-1 and S-2 left during today's inspection. S-3 has cleared fingerprints, but fingerprints were not transferred over. S-3 fingerprints were transferred during today's inspection. 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.
LPA Samantha Yip
informed Director Catrina Kalesh that this report dated 08/26/2022 documents two Type A citations which shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.
Also, LPA Samantha Yip informed the Director to provide a copy of this licensing report dated
08/26/2022 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
As a result of this inspection, Type A and Type B deficiencies were issued. A civil penalty for caregiver background check was assessed.
Exit interview conducted and report was reviewed with the Director Catrina Kalesh. A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME:
Joel Segura
TELEPHONE:
(408) 334-8550
LICENSING EVALUATOR NAME:
Samantha Yip
TELEPHONE:
(408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE:
08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/26/2022
LIC809
(FAS) - (06/04)
Page:
4
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Document Has Been Signed on
08/29/2022 08:22 AM
- 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:
SVCC-PACIFIC WEST CHRISTIAN ACADEMY PRE.
FACILITY NUMBER:
434411994
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/26/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(1)
Criminal Record Clearance
(e) 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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 6 person, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/29/2022
Plan of Correction
1
2
3
4
S-1 and S-2 left during inspection and understand that they cannot return until their fingerprints are cleared and associated to facility.
Director will send proof to Request for Livescan to Licensing.
Type A
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance
(e) 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: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 person, which poses an immediate health, safety or personal rights risk to persons in care. S-3 has cleared fingerprints, but did not transfer fingerprints to facility number.
POC Due Date:
08/26/2022
Plan of Correction
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2
3
4
Deficiency correct during today's inspection. Director submitted transfer request.
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:
Joel Segura
TELEPHONE:
(408) 334-8550
LICENSING EVALUATOR NAME:
Samantha Yip
TELEPHONE:
(408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE:
08/26/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/26/2022
LIC809
(FAS) - (06/04)
Page:
5
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Document Has Been Signed on
08/29/2022 08:22 AM
- 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:
SVCC-PACIFIC WEST CHRISTIAN ACADEMY PRE.
FACILITY NUMBER:
434411994
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/26/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101215.1(m)
Child Care Center Director Qualifications and Duties
(m) A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviews, the licensee did not comply with the section cited above. Director does not have proof to completion of 16 hours of health and safety training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/09/2022
Plan of Correction
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2
3
4
Director will send proof of enrollment to Licensing.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviews, the licensee did not comply with the section cited above in 2 out of 10 persons, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/16/2022
Plan of Correction
1
2
3
4
By POC 09/16/2022, Director will submit physician's report for Ref # 4 and Ref #9 to Licensing.
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:
Joel Segura
TELEPHONE:
(408) 334-8550
LICENSING EVALUATOR NAME:
Samantha Yip
TELEPHONE:
(408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE:
08/26/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/26/2022
LIC809
(FAS) - (06/04)
Page:
6
of
14
Document Has Been Signed on
08/29/2022 08:22 AM
- 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:
SVCC-PACIFIC WEST CHRISTIAN ACADEMY PRE.
FACILITY NUMBER:
434411994
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/26/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records, the licensee did not comply with the section cited above in 3 out of 10 persons, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/02/2022
Plan of Correction
1
2
3
4
By POC 09/02/2022, Director will have parents of Ref #2, #5, and #6 fill out the form and send proof to Licensing.
Type B
Section Cited
CCR
101223(b)(1)
Personal Rights
(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviews, the licensee did not comply with the section cited above in 3 out of 10 persons, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/02/2022
Plan of Correction
1
2
3
4
By POC 09/02/2022, Director will have parent of Ref #2, #8, and #9 fill out form and send proof to Licensing.
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:
Joel Segura
TELEPHONE:
(408) 334-8550
LICENSING EVALUATOR NAME:
Samantha Yip
TELEPHONE:
(408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE:
08/26/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/26/2022
LIC809
(FAS) - (06/04)
Page:
7
of
14
Document Has Been Signed on
08/29/2022 08:22 AM
- 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:
SVCC-PACIFIC WEST CHRISTIAN ACADEMY PRE.
FACILITY NUMBER:
434411994
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/26/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229.1(a)(1)
Sign in and Sign out (a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in. LPA observed that there were 29 children present, but there was 15 children signed in, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/02/2022
Plan of Correction
1
2
3
4
By POC 09/02/2022, Director will submit plan on how she will ensure that children are sign in and out at all times.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Joel Segura
TELEPHONE:
(408) 334-8550
LICENSING EVALUATOR NAME:
Samantha Yip
TELEPHONE:
(408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE:
08/26/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/26/2022
LIC809
(FAS) - (06/04)
Page:
14
of
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