434413103-10-27-2022-07-CC-SYIP-CKLKC2-20221027074625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413103
Report Date: 10/26/2022
Date Signed: 10/27/2022 07:46:29 AM

Document Has Been Signed on 10/27/2022 07:46 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:	CROSSROADS CHRISTIAN SCHOOL PRESCHOOL		FACILITY NUMBER:	434413103
ADMINISTRATOR:	COFFELT, HELENA		FACILITY TYPE:	850
ADDRESS:	145 WRIGHT AVENUE		TELEPHONE:	(408) 779-8850
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	46	CENSUS: 14	DATE:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Helena Coffelt		TIME 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) Samantha Yip conducted an unannounced Required- 1 Year inspection. LPA met with Director Helena Coffelt and explained the reason for the inspection. Present during today's inspection were 14 children and at least 4 staff. At 2:45PM, LPA observed that there was a child in the girl's restroom and one child in the boy's restroom. There was a staff standing at the boy's restroom; however, cannot visually supervise child in the girl's restroom. Director understands that children need to be supervised at all times, including visually. The hours of operation were Monday through Friday 7AM to 5:30PM. There is working phone at the facility. LPA toured the inside and outside of the facility with Director. Disinfectant, cleaning supplies, and other items that could be dangerous to children were inaccessible. LPA observed that there were containers of disinfectant wipes that were in a closet, which were accessible to children. Staff moved disinfectant wipes moved wipes to a shelf that is inaccessible. There are toys and equipment for children. Director stated that there no weapons, such as firearms, stored on the premise. There is a fully charged fire extinguish, smoke detector, and carbon monoxide. The last disaster drill was conducted on 10/20/2022. The outdoor area is fenced. Area around play structure has resilient material. LPA did observed that the resilient material by the slide was starting to get low. LPA discussed with Director to ensure that areas around play structures have enough resilient materials. There were no bodies of water observed during today's inspection. ----------------------continues on 809 dated 10/26/2022 page 2--------------------

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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: CROSSROADS CHRISTIAN SCHOOL PRESCHOOL	FACILITY NUMBER: 434413103
	VISIT DATE: 10/26/2022

NARRATIVE

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--------------------continuation of 809 dated 10/26/2022 page 1-------------------

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

Facility does provide Incidental Medical Services (IMS). LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records for three children. C-4 had medication on site, but expired on 08/2022. All children were missing physician's order. For IMS information, see PIN 22-02-CCP. 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.

Seven children's files were reviewed during today's inspection. The records reviewed include but not limited to admission agreement and physician's report. LPA observed that C-1 did not have physician's report on file. LPA also observed that C-2 did not have screening for TB risk factor checked off on physician's report. C-3 had a doctor's report, but did not include the information on the physician's report included.

5 staff files were reviewed during today's inspection. The records reviewed include but not limited to education credit and Mandated Reporter training. Staff completed CPR/1st Aid training on 08/2021 through American Safety & Health Institute, but did not have proof that it is EMSA approved. Director will verify that program is EMSA approved and send proof to Licensing. LPA observed that S-1 was missing verification of completion of a course. S-2 was missing the second page of LIC 508 and LIC 501. S-3 was missing the second page of the LIC 508.

----------------------continues on 809 dated 10/26/2022 page 3--------------------

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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: CROSSROADS CHRISTIAN SCHOOL PRESCHOOL	FACILITY NUMBER: 434413103
	VISIT DATE: 10/26/2022

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----------------continuation of 809 dated 10/26/2022 page 2-----------------------

All adults present have cleared fingerprints. 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.

Director will submit the following:
- C-1 and C-2's physician's report
- C-3: screening for TB risk screening
- C-4 updated epi-pen
- verification that American Safety and Health Institute is EMSA approved

As a result of this inspection, Type B citations were issued. Exit interview conducted and report was reviewed with Director Helena Coffelt. 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: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/27/2022 07:46 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: CROSSROADS CHRISTIAN SCHOOL PRESCHOOL	FACILITY NUMBER: 434413103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101229(a)(1)

Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. LPA observed that there was a child in girl's restroom and a child in the boy's restroom. There was staff standing by the boy's restroom. Staff did check on the child in the girl's restroom, but then went back to the boy's restroom.
	POC Due Date: 11/04/2022
	Plan of Correction
1 2 3 4	By POC, Director will conduct training with staff on supervision and send list of staff who attended training. Director will send plan outlining how children will be supervised at all time.

Type B

Section Cited

CCR

101226(e)(3)

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. 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 1 out of 3 persons, which poses a potential health, safety or personal rights risk to persons in care. C-4 had an expired epi-pen.
	POC Due Date: 11/30/2022
	Plan of Correction
1 2 3 4	By POC 11/30/2022, Director will send proof to C-4's epi-pen.

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: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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