434415475-4-27-2021-07-CC-MSEA-C34J78-20210517064728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 434415475
Report Date: 04/27/2021
Date Signed: 04/27/2021 12:32:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2021 and conducted by Evaluator Janet Tse

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20210420112028

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: 60	DATE:	04/27/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Hannah Park		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff forced day care child to sleep
Staff handled day care child in a rough manner
Staff did not prevent day care child from engaging in inappropriate behaviors

INVESTIGATION FINDINGS:

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LPA Janet Tse met with site director Hannah Park via Facetime due to COVID-19 to conduct an investigation visit for the above allegations. LPA explained the nature of today's inspection to Site Director. LPA toured the facility, and observed 8 children with one teacher in the Zion (Kindergarten) Room, 10 children with one teacher and one teacher assistant in the Sinai (Pre-K) Room, 14 children with one teacher and one co-teacher in the Mariah (Pre-K) Room, 11 children with one teacher and one co-teacher in the Olivet (2 and 3 years) Room, 11 children with one teacher and one co-teacher in the Carmel (2 and 3 years) Room, and 6 children with one teacher and one teacher assistant in the Nebo (2 and 3 years) Room.

A roster of the children was emailed to LPA during the inspection. LPA interviewed the Site Director today. Information gathered from the interview indicates that day care children are required to nap during nap time and are not allowed to get off the mat; but activities are not provided to encourage children to stay quietly or rest on the mat. While a day care child refused to stay on the mat and has become physically violent, a staff forced the child to stay on the mat. The child's inappropriate behaviors could've been prevented if the preschool has implemented proper measures and policies in regards to napping.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 07-CC-20210420112028

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/27/2021

NARRATIVE

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Based on LPA's observations and interview which was conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12 & Chapter 1), are being cited on the attached LIC 9099D.

LPA discussed the requirements of AB633 to Site Director and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) via email and Site Director understands the requirements. Upon receipt, Site Director shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Notice of site visit was issued and must be posted with the type A deficiencies cited in a prominent, publicly accessible area in the center for 30 days.

Due to COVID 19, a copy of this Licensing report with LPA's signature alone will be emailed to Site Director; and in lieu of Site Director's signature, a read receipt of the email will serve as acknowledgement of receipt of this Licensing report by Site Director.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 07-CC-20210420112028

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/28/2021 Section Cited CCR 101223(a)(3)	1 2 3 4 5 6 7	Personal Rights. The licensee shall ensure that each child is accorded the following personal rights:...To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature ... This requirement was not met as evidenced	1 2 3 4 5 6 7	The Site Director shall implement a revision of the napping policy whereas day care children cannot be forced to nap during nap time, and forward a copy of the revised policy to LPA by 04/28/2021 due date.
	8 9 10 11 12 13 14	by: Day care children are required to nap during nap time and are not allowed to get off the mat; and while a day care child refused to stay on the mat and has become physically violent, a staff forced the child to stay on the mat. This poses an immediate risk to the Health, Safety, or Personal Rights of children in care.	8 9 10 11 12 13 14	AB633 Parent Notification is required. This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
Type A 04/28/2021 Section Cited CCR 101223(a)(1)	1 2 3 4 5 6 7	Personal Rights. The licensee shall ensure that each child is accorded the following personal rights: To be accorded dignity in his/her personal relationships with staff and other persons... This requirement was not met as evidenced by: The child's inappropriate behaviors could've been prevented if the preschool	1 2 3 4 5 6 7	The Site Director shall implement a revision of the napping policy whereas day care children cannot be forced to nap during nap time, and forward a copy of the revised policy to LPA by 04/28/2021 due date.
	8 9 10 11 12 13 14	has implemented proper measures and policies in regards to napping.	8 9 10 11 12 13 14	AB633 Parent Notification is required. This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

LIC9099 (FAS) - (06/04)

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