434415475-11-12-2024-07-CC-MKAR-DATS9A-20241108124024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415475
Report Date: 11/08/2024
Date Signed: 11/12/2024 08:42:00 AM

Document Has Been Signed on 11/12/2024 08:42 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	SHALOM CHRISTIAN ACADEMY LLC		FACILITY NUMBER:	434415475
ADMINISTRATOR/ DIRECTOR:	HANNAH PARK		FACILITY TYPE:	850
ADDRESS:	1190 BENTON STREET		TELEPHONE:	(408) 352-5415
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95050
CAPACITY: 105	TOTAL ENROLLED CHILDREN: 83	CENSUS: 66	DATE:	11/08/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:39 AM
MET WITH:	Hannah Park and Jasen Chin		TIME VISIT/ INSPECTION COMPLETED:	12:55 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 Analyst(LPA), Mandeep Kaur met with Director, Hannah Park and General Manager(GM), Jasen Chin for an unannounced Annual/Random inspection. The purpose of today's inspection was explained with Director and General Manager. Facility's License, Notification of Parents’ Right Poster, Child Car Seat Law, Personal Rights (LIC 613A), Emergency Disaster Plan, Menus, Activity Schedule, and Earthquake Preparedness Checklist were observed to be posted. The preschool program has a active waiver: outdoor space.. The center's operating hours are Monday through Friday from 8:30am- 5:30pm. The facility is licensed to serve children ages 2 years to entry into first grade in Rooms:#1,#2,#3,#4,#5, and #6. LPA toured the indoor and outdoor areas of the facility with Director. LPA observed that the teacher-child ratio was in compliance. Fire drill was conducted on November 1, 2024. The facility has current children's roster and a copy was provided to LPA during the inspection. Cleaning products, disinfectants, sharp objects were stored inaccessible to children. Furniture and equipment were observed to be age appropriate and in good condition. The facility is clean. The bathrooms for children and staff are clean, sanitary, and operable. LPA observed 10 toilets and 9 sinks available for the children. Director stated that the center has a third party cleaning service that comes and clean the facility every weekend and cleaned by all staff on daily basis through out the day. The center provides morning snacks, lunch, and afternoon snacks to the children. There is a kitchen at the facility for food preparation. The kitchen is equipped with refrigerators, stove, oven, microwave, dishwasher, storage space for food, and a sink with hot and cold running water. Drinking water is available for the children indoor via filtered water and individual sippy cups. LPA observed trash cans with tight fitting covers for the disposable of solid waste. Healthy Beverages requirements were discussed and document provided. The facility has fire extinguishers and working smoke and carbon monoxide detectors. Continuation on next pages:

Belinda Devall	TELEPHONE: (408) 598-5501
Mandeep Kaur	TELEPHONE: 408-334-8320
	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHALOM CHRISTIAN ACADEMY LLC	FACILITY NUMBER: 434415475
	VISIT DATE: 11/08/2024

NARRATIVE

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The playground is surrounded with appropriate fencing. Shade is provided. Drinking water is readily available for the children outdoor via filtered water and individual sippy cups. There were no bodies of water observed. Director stated that there are no weapons or firearms on the premises.

LPA reviewed 6 random children's files. Children records reviewed include Admission Agreement, Identification and Emergency Information, Consent for Emergency Medical Treatment, Physician's Report, TB test, Immunizations, Parent Right's Receipt, Personal Rights, and Health History.

LPA reviewed 6 staff files. Staff records reviewed include Employee Rights, Statement Acknowledging Requirement to Report Child Abuse, Health Screening Report with TB Clearance, Immunizations (Measles,
Pertussis, and Influenza) and required training. LPA reminded Director that the Mandated Reporter Training shall be renewed by all staff every two years. At least one staff member present during the inspection has current Pediatric CPR/First Aid certifications.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at:https://www.ada.gov/resources/child-care-centers/.

Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Continuation on next page:

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Mandeep Kaur	TELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHALOM CHRISTIAN ACADEMY LLC	FACILITY NUMBER: 434415475
	VISIT DATE: 11/08/2024

NARRATIVE

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Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP).

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&R's) throughout California.

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.

No deficiency is issued during today's inspection.

Exit interview conducted and report was reviewed with Director, Hannah Park.

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

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Mandeep Kaur	TELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

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