434415781-2-12-2024-07-CC-MMOO-D2DSKA-20240212125625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415781
Report Date: 02/12/2024
Date Signed: 02/12/2024 12:57:58 PM

Document Has Been Signed on 02/12/2024 12:57 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:	LIN, EDWARD		FACILITY TYPE:	850
ADDRESS:	940 S STELLING ROAD		TELEPHONE:	(408) 352-5756
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	56	CENSUS: 15	DATE:	02/12/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Edward Lin		TIME COMPLETED:	01:10 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) Marilou Monico met with Site Director, Edward Lin, for an unannounced Required - 3 Year Inspection. The purpose of today's inspection was explained with Edward. 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 facility has no active waivers. The center's operating hours are Monday through Friday from 09:00 AM to 5:00 PM. The facility is licensed to serve children ages 2 years to entry into first grade in Rooms 1 and 2. LPA toured the indoor and outdoor areas. LPA observed that the teacher-child ratio was in compliance. Fire drill was conducted on December 7, 2023. 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 3 toilets, 1 urinal, and 4 sinks available for the children. Site Director stated that staff cleans the facility after daycare hours every day and the facility also has a third party cleaning service that comes three times a week after daycare hours to clean the facility. The center provides morning and afternoon snacks to the children. There is a kitchen located adjacent to Room 1. The kitchen is equipped with refrigerator, stove, microwave, and a sink with hot and cold running water. Drinking water is available for the children indoor via water dispenser and individual water bottles. LPA observed trash cans with tight fitting covers for the disposable of solid waste. The facility has fire extinguishers and working smoke and carbon monoxide detectors. The playgrounds are surrounded with appropriate fencing and the outdoor surfaces are safe. Shade is provided by trees, sails, and building overhang. Drinking water is readily available for the children outdoor via individual water bottles. LPA observed climbing structures with resilient material (rubber foam & synthetic grass) under and around the structures. There were no bodies of water observed. Edward stated that there are no we weapons or firearms on the premises. *Continuation on next pages:*

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOOD SHEPHERD CHRISTIAN SCHOOL	FACILITY NUMBER: 434415781
	VISIT DATE: 02/12/2024

NARRATIVE

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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 3 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 Site 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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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/resources/child-care-centers/.

Site Director, Edward Lin, 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.

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

Site Director, Edward Lin, 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.

Continuation on next page:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOOD SHEPHERD CHRISTIAN SCHOOL	FACILITY NUMBER: 434415781
	VISIT DATE: 02/12/2024

NARRATIVE

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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.

As a result of this inspection, Type B deficiency was cited on the following page:

Exit interview conducted and report was reviewed with Site Director, Edward Lin.

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

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/12/2024 12:57 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101226(e)(3)(B)

Health-Related Services

(3) Prescription medications may be administered if all of the following conditions are met: (B) For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, three children (C1, C2, & C3) are missing consent and instructions in writing from the authorized representative for the administration of Epipen. This poses a potential risk to the health, safety or personal rights to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	By 02/16/24, Edward states that he will submit a written plan to ensure that prior to administration of medication, a written consent from the parents/authorized representative must be obtained.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC809 (FAS) - (06/04)

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