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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415781
Report Date: 05/07/2025
Date Signed: 05/07/2025 12:21:04 PM

Document Has Been Signed on 05/07/2025 12:21 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GOOD SHEPHERD CHRISTIAN SCHOOLFACILITY NUMBER:
434415781
ADMINISTRATOR/
DIRECTOR:		LIN, EDWARDFACILITY TYPE:
850
ADDRESS:940 S STELLING ROADTELEPHONE:
(408) 352-5756
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 56TOTAL ENROLLED CHILDREN: 28CENSUS: 15DATE:
05/07/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Edward LinTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On May 7, 2025 at 9:08 AM, Licensing Program Analyst (LPA), Marilou Monico, met with Site Director, Edward Lin, for an unannounced Annual Random Inspection. LPA provided Site Director the Entrance Checklist (LIC 125). The facility operates Monday thru Friday from 8:30 AM to 5:30 PM. The preschool program serves children ages 2 years old to entry into first grade in Rooms 1 & 2.

LPA toured the indoor and outdoor areas of the facility. LPA observed all the required posted materials. The facility is within ratio & capacity compliance today. The classrooms have age-appropriate materials, toys, furnishings, equipment, & adequate storage for children’s belongings. The children's napping equipment were observed to be stored in a healthful manner. Bedding is provided by parents and is washed weekly. LPA observed functioning smoke and carbon monoxide detectors. Each room has fully charged fire extinguisher. The isolation area for sick children is the office or lobby area.

The center provides morning and afternoon snacks to children. Parents provide lunch. All center provided food items are properly labeled & stored separately from cleaning supplies. There is a kitchen at the facility for food preparation. The kitchen is equipped with refrigerator, microwave, toaster, and a sink with hot and cold running water. Snack menu is posted one week in advance, available for review, & dated. Solid waste bins are equipped with tight fitting lids. Drinking water is accessible by children in the classrooms via water bottles and water dispenser. The facility has separate staff and children bathrooms and are clean, sanitary and operable.

The outdoor play areas are fully fenced. Shade is provided by trees and building overhang . All equipment and surfaces are free from hazards. There are no bodies of water on the premises. There are age-appropriate outdoor toys and materials for the children. The play structures are securely installed into the ground and the ground surrounding the play structure is sufficiently padded and in good condition for safety. Drinking water is provided in water bottles. Per Site Director, there are no firearms or weapons on the premises.

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Gladys KuizonTELEPHONE: (510) -56-5850
Marilou MonicoTELEPHONE: (408) 334-8549
DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: GOOD SHEPHERD CHRISTIAN SCHOOL
FACILITY NUMBER: 434415781
VISIT DATE: 05/07/2025
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All individuals subject to criminal record review have fingerprint clearances and associated to the facility. LPA reviewed the facility roster. At least one staff member has a current Pediatric CPR/First-Aid Certification. LPA observed all required postings in a publicly accessible area. LPA reviewed the sign in/out sheets for the month of May 2025. Fire/disaster drill was conducted on January 15, 2025.

LPA reviewed ten (10) random children files during today's inspection for the following records: Admission Agreement, Personal Rights (613A), Identification and Emergency Information (LIC700), Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Physician’s Report (LIC 701) and Immunization records. LPA observed that two children (C1 & C2) who have medications at the facility do not have the written consent from authorized representative regarding administration of medication.



LPA reviewed three (3) staff (S1-S3) files for the following records: Health Screening Report (LIC 503), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), Employee rights (LIC 9052), staff qualifications, immunization records, and required training. Site Director was reminded of their responsibility to renew CPR/First Aid and Mandated Reporter certificates every two years.

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.

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.


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SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
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: GOOD SHEPHERD CHRISTIAN SCHOOL
FACILITY NUMBER: 434415781
VISIT DATE: 05/07/2025
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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.

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 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&Rs) throughout California.

LPA reminded Site Director to report unusual incidents or injuries to children in care to the Department of Social Services using the Unusual Incident/Injury Report form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 calendar days.

As a result of this inspection, Type B deficiency is cited on the following page.

A Notice of Site Visit was given and must remain posted for 30 days.



Exit interview conducted and report was reviewed with Site Director, Edward Lin.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2025 12:21 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
SAN JOSE CC RO, 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: 05/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation and record review, the licensee failed to obtain written consent for the administration of medication from the authorized representatives of two children (C1 & C2) in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
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Site Director states that he will submit written consent from the two children's authorized representatives by 05/12/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys KuizonTELEPHONE: (510) -56-5850
Marilou MonicoTELEPHONE: (408) 334-8549

DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025

LIC809 (FAS) - (06/04)
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