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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414503
Report Date: 11/09/2021
Date Signed: 11/12/2021 02:54:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:ST. THOMAS PRESCHOOLFACILITY NUMBER:
434414503
ADMINISTRATOR:EFREN LORENZ TIGASFACILITY TYPE:
850
ADDRESS:200 NORTH ABBOTT AVENUETELEPHONE:
(408) 946-0190
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:68CENSUS: 30DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Efren Lorenz TigasTIME COMPLETED:
02:00 PM
NARRATIVE
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On Tuesday, November 9, 2021 9:08 am, Licensing Program Analyst (LPA) Manel Estoesta conducted an unannounced Required One (1) Year Visit. LPA met with the Director Efren Lorenz Tigas (Facility Representative) and explained the nature of site visit. Present on this visit were 6 staff and 30 preschool children. Facility operates from Monday to Friday 8 am to 6 pm.
LPA toured the facility to conduct a Health and Safety Inspection with the Facility Representative. Facility’s License, Parents’ Rights Poster, Personal Rights, Activity Schedules, and Waivers were observed to be posted. Facility was observed to be in compliance with teacher to children ratio requirement. Children were engaged in various activities under the visual supervision of the teachers.
Facility has a total of 2 operating classroom, Dolphin/Parrot Room and Rainforest/Butterfly Room. The classrooms, restrooms, storage room and office area were inspected. Only cold water is available in the children's sinks. Two 2 bathroom (1 for staff and 1 for children) are located in the church building close to the staff lounge and another outdoor children's bathroom located next to the outdoor storage area. The facility representative stated that children are being assisted and supervised when using the bathroom. The sick child will use the staff bathroom if needed. The sick child will be isolated in the multi-purpose room located in the church building. Restrooms for children's use were observed to be in safe, sanitary, and functioning condition.
Director stated that facility does not possess nor store any weapons on the premises. Disinfectants, cleaning solutions, and other items that are dangerous to children were stored inaccessible to children. Cabinets, drawers, and room used for storage were locked. Furniture and equipment such as mats, cots, tables, and chairs were age appropriate and were in good condition, free of sharp, loose, or pointed parts. Floors were clean and free from tripping hazard.
Outdoor activity space are fenced and play equipment were maintained in a safe condition and free of hazards. There were no bodies of water observed. Areas around and under high climbing equipment and slides were cushioned with material that absorbs falls. There were shaded rest areas for children. Drinking water are arranged to be readily available to children during indoor and outdoor activities.
SEE 809 C.......
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ST. THOMAS PRESCHOOL
FACILITY NUMBER: 434414503
VISIT DATE: 11/09/2021
NARRATIVE
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CONTINUATION....
There is no kitchen in the facility. Facility Representative stated that children brings their lunch and facility provides am and pm snacks. Trash cans for solid waste had tight-fitting covers on, and were in good repair.
Facility does not provide transportation for children but Director understands that children cannot be left alone, unattended in park vehicles.
Fire extinguisher was last serviced on July 2021. LPA observed Smoke and Carbon Monoxide Detectors, and fire pull stations. Log shows that the Fire Drill and Earthquake drill was conducted monthly and last conducted May of 2021. Facility Fire Department Inspection Permit expires on 12/31/2021.
Facility files were reviewed. Children sign in and out procedures and logs were reviewed. Facility is currently using an electronic fingerprint sign in and out system trough Procare app. A sampling of Children's files was reviewed. The records reviewed include Admission Agreement, Identification and Emergency Information, Medical Assessment and Immunization.
A sampling of Staff's files was taken for review. Staff sign in and out procedures and logs were reviewed. The record's reviewed include: Criminal Record and Child Abuse Index Clearance, Health Screening Report with TB Clearance, Education Qualification, records of immunization (Measles and Pertussis), and Training such as the AB1207 Mandated Reporter Certification. There was at least one Teacher with current certification in Pediatric CPR and First Aid present at the facility during inspection.
LPA provided and discussed the following;
1. Santa Clara County Office of Education, Childcare Resource & Referral Program 1290 Ridder Park Drive San Jose, CA 95131-2304 Email: childcarescc@sccoe.org Phone: 669-212-KIDS (5437) Hours: Monday – Friday 8:30 a.m.– 4:30 p.m. https://www.childcarescc.org/child-care-application
2. For questions about registration or your stipend, please call 1-833-398-1399 Hours of operation are 6:00am – 6:00pm CST ARPASurvey@cde.ca.gov
3. PIN 21-21-CCP RELEASE OF THE WRITTEN DIRECTIVES FOR LEAD TESTING OF WATER IN LICENSED CHILD CARE CENTERS PER AB 2370.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual -Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated 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
SEE 809 C.....
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ST. THOMAS PRESCHOOL
FACILITY NUMBER: 434414503
VISIT DATE: 11/09/2021
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CONTINUATION.........
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/inspection-process.

Facility representative 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 discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

The following is a regulatory violation was observed during the visit;


At 10am during the staff record review, LPA observed that one (1) teacher has an Inactive Criminal Record Background Clearance, not associated to the facility and in violation of Staff Records CCR 101170(e)(1). Please see 809 D.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director Efren Lorenz Tigas.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: ST. THOMAS PRESCHOOL
FACILITY NUMBER: 434414503
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2021
Plan of Correction
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The Facility Representative will request for a background check and fingerprint clearance by the POC above date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4