434411994-10-10-2022-07-CC-SYIP-CK3LDG-20221010083951

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411994
Report Date: 10/07/2022
Date Signed: 10/10/2022 08:39:55 AM

Document Has Been Signed on 10/10/2022 08:39 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: 36	DATE:	10/07/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Catrina Kalesh		TIME COMPLETED:	12:50 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 Case Management-Other inspection. LPA met with Director Catrina Kalesh and explained the reason for the inspection. The purpose of this inspection is facility was cited on 08/26/2022 for children's file, director not completing health and safety training, sign in/sign out, and fingerprints. Facility had an extension on the Plan of Correction for 09/16/2022. During today's inspection, LPA reviewed sign in/sign out sheet, children's file, and director file. LPA observed that Room 106 had two children signed in, but there were 6 children present. All other children present were signed in. LPA reminded Director that that date needs to be included in the sign in/sign out. Director will send written plan on how she will ensure children are signed in and out to Licensing by 10/12/2022. LPA reviewed C-1 and C-2's file during today's inspection. C-1 and C-2 are still missing physician's report in file. Director followed-up with parents during inspection. Director will send physician's report to Licensing by 10/31/2022. LPA requested during inspection for Director to send paperwork to Licensing, but have not received it yet. LPA reviewed Director's file during today's inspection. LPA obtained a copy of Director file during today's inspection. Director is scheduled to complete the CPR/1st Aid on 10/20/2022. LPA provided Director a list of additional forms that need to be submitted to Licensing in order to change her to Director. Director will send additional paperwork for herself by 10/24/2022. -------------------continues on 809 dated 10/07/2022 page 2-----------------------

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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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Document Has Been Signed on 10/10/2022 08:39 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: 10/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/10/2022 Section Cited	1 2 3 4 5 6 7	(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:
	8 9 10 11 12 13 14	Based on record review, S-1, S-2, and S-3 were present at the faciltiy and did not have cleared fingerprints, which poses a immediate risk to the health and safety to the children in care.	8 9 10 11 12 13 14	Director understands that staff cannot be present until they have cleared fingerprints. Director will check with Licensing or on Guardian that staff have cleared fingerprints and are associate prior to them returning to the faciltiy.
	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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 10/07/2022

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----------------continuation of 809 dated 10/07/2022 page 2-----------------------

During today's inspection S-1, S-2, and S-3 were present at the facility and does not have cleared fingerprints. Director sent S-1, S-2, and S-3 home during today's inspection and had them complete their Livescan. Director understands that staff cannot be present until their fingerprints are cleared and associated. Director will check with Licensing or Guardians that staff's fingerprints are cleared and associated prior to them returning to the facility.

Facility will submit the following:

C-1 and C-2's physician's report
written plan on how facility will ensure children are signed in and out
additional forms needed for director

LPA Samantha Yip informed Director Catrina Kalesh that this report dated 10/07/2022 documents one Type A citation 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 10/07/2022 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, a Type A deficiency was issued. Civil penalties were assessed for caregiver background check and repeat violation.

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. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC809 (FAS) - (06/04)

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