434415781-7-20-2021-07-CC-MMOO-C54QTY-20210720122755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415781
Report Date: 07/20/2021
Date Signed: 07/20/2021 12:28:09 PM

Document Has Been Signed on 07/20/2021 12:28 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:	GOOD SHEPHERD CHRISTIAN SCHOOL		FACILITY NUMBER:	434415781
ADMINISTRATOR:	NGUYEN, SYLVIA		FACILITY TYPE:	850
ADDRESS:	940 S STELLING ROAD		TELEPHONE:	(408) 352-5756
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY: 56	TOTAL ENROLLED CHILDREN: 0	CENSUS: 18	DATE:	07/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Edward Lin & Joseph Chiu		TIME COMPLETED:	12:40 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	#2 Licensing Program Analysts (LPAs) Marilou Monico and Aman Sharma conducted an unannounced Required - 1 Year Inspection. LPAs met with Program Administrator, Edward Lin, and Licensee Representative, Joseph Chiu, and informed them the purpose of today's inspection. Facility's License, Notification of Parents’ Right Poster, Child Car Seat Law, Personal Rights (LIC 613A), Emergency Disaster Plan, and Earthquake Preparedness Checklist were observed to be posted. The center's operating hours are Monday through Friday 07:00 AM to 6:30 PM. Age serve is 18 months to entry into first grade. LPAs toured the facility both indoor and outdoor. The classrooms, restrooms, and storage areas were inspected. LPAs observed that the facility was operating in compliance with teacher to children ratio requirement. Children were engaged in activities under the supervision of teachers. There were no bodies of water observed. LPAs observed that the Toddler Option Classroom was used by children ages 4 1/2 years old to entry into first grade instead of children ages 18 months to 36 months. Program Administrator stated that facility do not have weapons on the premises. Furniture and equipment were observed to be age appropriate and in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, and other items that are dangerous to children were stored inaccessible to children. Restrooms for children to use were observed to be in operating conditions. Floors were clean. Outdoor activity spaces are enclosed by fencing and are observed to be free of hazards. LPAs observed play equipment were in good condition and areas around high climbing equipment have resilient material to absorb falls. Drinking water was readily available to children indoor and outdoor. Activities schedule and Menus were posted. Facility provides morning and afternoon snacks. Snacks are prepared at the facility. LPAs observed that food storage areas were clean and free of litter.

SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

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: GOOD SHEPHERD CHRISTIAN SCHOOL	FACILITY NUMBER: 434415781
	VISIT DATE: 07/20/2021

NARRATIVE

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Foods and beverages were kept protected against contamination and spoilage. Trash cans for solid waste had tight-fitting covers on, and were in good repair. First Aid Kit was inspected. Fire extinguisher, smoke and carbon monoxide detector were observed.

Incidental Medical Services Plan was submitted to Licensing. Program Administrator stated that at this time, they don't have children enrolled who are using medication.

LPAs reviewed sign in and out procedurse. Sampling of children and staff files was taken for review during today's inspection. LPAs reminded Program Administrator that the online AB1207 Mandated Reported Training needs to be renewed every two years. There was at least one person with current certification in Pediatric CPR and First Aid present at the facility.

LPAs reminded Program Administrator of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.

In the areas that were evaluated, one regulatory violation was observed at the time of the visit; therefore a citation was issued. Exit interview was conducted, where this report, the citation, plan of correction, and appeal rights were reviewed with Program Administrator.

A copy of this report was provided to the facility at the conclusion of the inspection.

NOTICE OF SITE VISIT WAS ISSUED. PROGRAM ADMINISTRATOR WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.

SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2021 12:28 PM - It Cannot Be Edited

Created By: Marilou Monico On 07/20/2021 at 11:28 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GOOD SHEPHERD CHRISTIAN SCHOOL	FACILITY NUMBER: 434415781
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/23/2021 Section Cited	1 2 3 4 5 6 7	Alterations to Existing Buildings or New Facilities - Prior to construction or alterations, the licensee shall notify the Department of the proposed change(s). This requirement was not met as evidenced by: LPAs observed that the Toddler Option Room was used for children ages 4 1/2 years old to entry into first grade. This poses a potential risk to the health and safety to children in care.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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:

Anthony Studebaker

LICENSING EVALUATOR NAME:

Marilou Monico

LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC809 (FAS) - (06/04)

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