434415475-7-28-2020-07-CC-TDON-BRXNBH-20200728101907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415475
Report Date: 07/27/2020
Date Signed: 07/28/2020 10:19:13 AM

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:	SHALOM CHRISTIAN ACADEMY LLC		FACILITY NUMBER:	434415475
ADMINISTRATOR:	DONG (LAURA) CHIN		FACILITY TYPE:	850
ADDRESS:	1190 BENTON STREET		TELEPHONE:	(408) 655-1773
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95050
CAPACITY:	105	CENSUS: 40	DATE:	07/27/2020
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Jasen Chin		TIME COMPLETED:	03:35 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) Tuoc Doan conducted a Tele-Case Management inspection via video conference call with Administrator Jasen Chin. Facility was informed that due to the COVID-19 situation and "Shelter in Place" Order, this LIC809 Facility Evaluation Report was generated at the Licensing Office and will be emailed to the facility. Facility’s reply to the email will serve as acknowledgement that the report was received. The Tele-Inspection is in response to Licensee’s request to remove the Toddler Component from the Preschool License. The square footage of Room 1 (Toddler Room) and the Toddler Yard will be added to the total available activity space for Preschool children moving forward. The Preschool Center is operating Monday through Friday, from 08:00 AM to 06:00 PM serving children ages 2 years until entry into first grade. The maximum licensed capacity of the Preschool remains at 105 children. Fire Clearance for 105 capacity was granted on 04/17/2019. The indoor and outdoor space were inspected through the conference call. Rooms 1, 2, 3, 4, 5 and 6 along with furniture, fixtures, and equipment were observed. LPA reviewed with Administrator and Director the available activity space based on previous measurements to confirm that the change meets the requirement of 35 square feet of indoor activity space and 75 square feet of outdoor activity space per child. The following are the measurements of activity space taken during the Pre-Licensing inspection on 10/17/2018 and Case Management inspection on 05/09/2019: Preschool Indoor Activity Space: Room 1 = 381.922 sq. ft. Room 2 = 423.591 sq. ft. Room 3 = 1,018.209 sq. ft.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc Doan	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2020

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: SHALOM CHRISTIAN ACADEMY LLC	FACILITY NUMBER: 434415475
	VISIT DATE: 07/27/2020

NARRATIVE

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Room 4 = 794.506 sq. ft.
Room 5 = 263.662 sq. ft.
Room 6 = 2,021.151 sq. ft.

Total Indoor Activity Space = (4,903.041 sq. ft.) divided by (35 sq. ft. / child)
= 140 Children

Preschool Outdoor Activity Space:
Playground A: 2,891.25 sq. ft.
Playground B: 554.228 sq. ft.
Playground C: 496.996 sq. ft.
Playground D: 577.390 sq. ft.

Total Preschool Outdoor Activity Space = (4,519.864 sq. ft.) divided by (75 sq. ft. / child)
= 60 Children

Facility has been granted a waiver to be licensed for a maximum capacity of 105 children even though outdoor activity space only measures for 60 children. Facility is implementing an outdoor activity schedule where no more than 60 children are using the outdoor activity space at one time.

There are three children restrooms with a total of 10 toilets and 9 sinks available for children to use and two adult restrooms. LPA observed soap dispenser and disposable paper towels in the restrooms. LPA reminded facility that detergents, cleaning compounds, sharps, medicines, and other items which could pose a danger if readily available to children are to be stored where they are inaccessible to children in care.

Exit Interview was conducted, where this report was reviewed with Administrator Jasen Chin.
Licensee’s request to remove the Toddler Component from the Preschool License is approved. Licensee will receive an updated Preschool Child Care Center License with the reflected change.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc Doan	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2020

LIC809 (FAS) - (06/04)

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