434413583-6-23-2023-07-CC-CNEN-CT3VTT-20230623164340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413583
Report Date: 06/23/2023
Date Signed: 06/23/2023 04:43:50 PM

Document Has Been Signed on 06/23/2023 04:43 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:	SAN JOSE CHRISTIAN PRESCHOOL		FACILITY NUMBER:	434413583
ADMINISTRATOR:	ASHLEY KOEPPLIN		FACILITY TYPE:	830
ADDRESS:	1300 SHEFFIELD AVENUE		TELEPHONE:	(408) 371-7741
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	12	CENSUS: 8	DATE:	06/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Monique Nicoleau		TIME COMPLETED:	04:55 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 Analysts (LPAs), Cortney Nelson and Ashley Lopez, met with Site Director, Monique Nicoleau, for an unannounced Required- 1 Year Inspection. LPA's were granted access to the facility by Monique and toured both indoors and outdoors during the inspection. The facility is located at San Jose Christian School in classroom #9, identified as the Caterpillar Room. Upon arrival, there were eight infants and two staff members present, which is compliant with the facility license capacity and ratio requirements. LPA observed all required postings near the entrance to the facility and the hours of operation are Monday – Friday, 8:00AM-5:00PM. LPAs reviewed digital sign-in/out sheets and observed the facility uses the Application, Procare. LPAs advised that full legal signature and time of day are the minimum requirements for sign-in/out. The fire/disaster drill log was reviewed and LPAs observed the last drill was conducted on 5/17/2023, which is compliant with the six-month requirement for facilities. LPAs observed a fully charged 2A10BC fire extinguisher and functioning carbon monoxide detector. The facility has a built in fire detection system. Monique states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. LPAs provided Monique with Parent Consent for Administration of Medications and Medication Chart (LIC9221) and Nebulizer Care Consent/ Verification Child Care Facilities (LIC9166) for future use with medication at the facility. There are no weapons or firearms on the premises. This facility provides Incidental Medical Services- IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Child Care Centers, Section 101173 and 101226. The following information regarding ADA was provided: US Department of Justice 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

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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: SAN JOSE CHRISTIAN PRESCHOOL	FACILITY NUMBER: 434413583
	VISIT DATE: 06/23/2023

NARRATIVE

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Indoor areas of the facility were inspected and observed to be clean, orderly, and safe for day care infants. The Infant room at the facility is physically separate from other childcare center components. LPAs observed sufficient age-appropriate materials, toys, and play equipment. Toys are safe and do not have sharp edges or small parts that may pose a choking hazard. Infant changing table was observed to be padded, within arms reach of a sink, in good repair and safe condition. Cribs used by the infants are free from loose articles, covered with a fitted sheet, and there are no objects hanging above or attached to the crib. LPAs advised sheets shall fit properly on the crib mattresses as they were observed to be too small and causing bowing of the mattress. LPAs additionally advised that baby walkers and inclined sleepers are not allowed in licensed facilities. The floors are clean and free of tripping hazards and waste containers have tight fitting lids.

All infants have Needs and Services plans and LPAs advised that plans shall be updated quarterly with authorized representatives and teacher/directors. LPAs reminded that all formula and bottles provided should be labeled individually with the child’s name and the date.

Infant Safe Sleep regulations (PIN 20-24-CCP) were discussed with Monique, including the Individual Infant Sleeping Plan (LIC9227). LPAs reminded that infants up to 12 months of age should be placed on their back to sleep and that infants should not be swaddled. LPAs advised that sleep saks are considered a swaddling device and shall not be used in child care centers. Infants should be supervised while sleeping and documentation of sleep checks every 15 minutes should remain in the infant’s file. Documentation should include the time of the check, the infant’s physical condition, and initials of the staff member checking on the infant.

The outdoor area was inspected and observed to be fenced in. The facility has a waiver for shared outdoor space for preschool and infant components and LPAs observed all conditions were met. Monique states that the infants are walked around the school campus in strollers and play outside on the flat surfaces. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by gazebo structure. Placement of playpens does not create a hazard for other infants or staff in the outdoor area.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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: SAN JOSE CHRISTIAN PRESCHOOL	FACILITY NUMBER: 434413583
	VISIT DATE: 06/23/2023

NARRATIVE

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Five infant files were reviewed and most documents were present. LPAs advised nap check documentation, Individual Infant Sleep Plan (LIC9227) for infants under 12 months, Personal Rights of Children (LIC613A), and updating Needs and Services Plan at least quarterly.

Two staff files were reviewed and most required documents were present. LPAs advised adding job application to the staff files and ensuring all staff complete health screening report (LIC503) not more than one year prior or within seven days of hire. There is at least one staff member present with current CPR/First-Aid that expires 10/2023 and current Mandated Reporter Training that expires on 10/21/2023. LPAs reminded both shall be renewed every 2 years.

LPAs reminded that the Site Director shall be on the premises during the hours the center is in operation and that infants at the center shall be visually supervised at all times. LPAs reminded that there shall be at least one person with valid CPR and First-Aid certifications on site at all times or present during off site activities, such as field trips.

Exit interview conducted and report was reviewed with the Site Director, Monique Nicoleau.

As a result of today’s inspection, deficiencies were cited, see LIC809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/23/2023 04:43 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: SAN JOSE CHRISTIAN PRESCHOOL	FACILITY NUMBER: 434413583
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101439.1(b)(1)

Infant Care Center Sleeping Equipment

(b) A crib or portable -crib meeting United States Consumer Product Safety Commission safety standards shall be provided for each infant who is unable to climb out of a crib. (1) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above for three out of eight cribs where the mattress was too small causing the mattress to bow, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	The Licensee shall order new mattress sheets and submit proof of order to the Department by 6/30/2023. LPAs advised using cool setting for drying as the sheets are washed daily and may have shrunk over time causing them to not fit on cribs.

Type B

Section Cited

CCR

101439(d)(2)

Infant Care Center Fixtures, Furniture, Equipment and Supplies

(d) Swings, playpens and all such equipment and furniture shall be assembled or installed according to the manufacturer's instructions, and shall be maintained in good repair and safe condition. (2) A baby walker shall not be allowed on the premises of a child care center in accordance with Health and Safety Code Section 1596.846. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as baby walkers and incliner sleepers were observed in the infant room, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	The Site Director removed baby walker and inclined sleepers from the infant room during todays inspections. LPAs advised swings may be used in infants room, however they may not be used once an infant falls asleep. Upon falling asleep, infants must be moved to a crib if the swing is used again.

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: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/23/2023 04:43 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: SAN JOSE CHRISTIAN PRESCHOOL	FACILITY NUMBER: 434413583
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101419.3(a)

Modifications to Infant Needs and Services Plan

(a) The written infant needs and services plan shall be updated at least quarterly, or as often as necessary to assure its accuracy. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above as four out of five infant files reviewed had plans over three months old, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	The Site Director will update needs and services plan all infants registered for the summer and submit to the Department by 7/7/2023. Any infants who will meet for updates after this date should have meeting date submitted for POC.

Type B

Section Cited

CCR

101429(a)(2)(C)

Responsibility for Providing Care and Supervision for Infants

(C) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above as there were no documented sleep checks and Individual Infant Sleep Plan (LIC9227) for infants under 12 months, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	The Site Director will create sleep check document for all infants enrolled and begin using immediately. All infants under 12 months of age will complete LIC9227 and add to their file. The Site Director will submit copies of completed LIC9227 and copy of nap check log that will be used to the Department by 6/30/2023.

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: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/23/2023 04:43 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: SAN JOSE CHRISTIAN PRESCHOOL	FACILITY NUMBER: 434413583
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 interview and record review, the licensee did not comply with the section cited above for five out of five infant files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	The Site Director will give authorized representatives a copy of the LIC613A and retain signed bottom portion in the infant files. Copies of signed LIC613A to be submitted to the Department by 6/30/2023.

Type B

Section Cited

CCR

101427(j)

Infant Care Food Service

(j) Bottles, dishes and containers of food brought by the infant's authorized representative shall be labeled with the infant's name and the current date. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as bottles did not have current date, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2023
	Plan of Correction
1 2 3 4	The Site Director is to immediately request parents clearly indicate the child's name and the date bottles/food/dishes are brought to the center. Photo of all bottles in the refrigerator with infant names and dates clearly indicated to be submitted to the Department by 6/26/2023.

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: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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