434416304-5-21-2021-07-CC-DMAC-C393QT-20210521182739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416304
Report Date: 03/30/2021
Date Signed: 05/21/2021 06:28:04 PM

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:	REHOBOTH PRESCHOOL/DAYCARE		FACILITY NUMBER:	434416304
ADMINISTRATOR:	MERAT AYALEW		FACILITY TYPE:	840
ADDRESS:	3275 WILLIAMS ROAD		TELEPHONE:	(408) 603-5251
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	40	CENSUS: 0	DATE:	03/30/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Merat Ayalew, Applicant Representative		TIME COMPLETED:	11:55 AM

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 Analysts (LPAs) Dung Mac and Mel Matos conducted a scheduled Tele-Pre-Licensing inspection via video conference call (FaceTime) with Merat Ayalew, Applicant Representative. The Applicant Representative is applying for a combination center (Preschool #434416302, Infant #434416303, and School-Age #434416304) on the same premises. The Facility is located on the premises of the Church. A Fire Clearance was approved by San Jose Fire Department on 3/08/2021.

The School-Age Center will operate Monday through Friday from 06:30AM to 06:00PM, serving school-age children ages 5-13 years. The School-age program will be in Room 4 & 5, Preschool program will be using Rooms 1 & 2 and the Infant program will be utilizing Room 3.

The facility was inspected inside and outside via video conference call (FaceTime). During today’s video conference call, the indoor/outdoor measurements were taken by Applicant Representative, Merat Ayalew, and a facility staff, as LPAs observed the measuring process and provided direction over the video conference call.

Indoor Activity Space:

Room 4: (29.333 x 42.000) - (12.000 x 1.167) = 1,217.98
Room 5: 15.167 x 32.000 = 485.34

TOTAL INDOOR SPACE: 1,703.33 sq. ft. divided by 35 = 48 school-age children

Room 4 will be used only for school activities. The Church uses this room for activities on weekends. Merat understands that facility will ensure that Room 4 should be safe and ready for school use during the school operating hours.

Report to be continued on Page #2

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: REHOBOTH PRESCHOOL/DAYCARE	FACILITY NUMBER: 434416304
	VISIT DATE: 03/30/2021

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
26
27
28
29
30
31
32

Report Continued from Page #1

School-age bathrooms are located outside Room #5 and allow for individual privacy. LPA observed dispenser soap and disposable towels in bathroom. Staff have a separate bathroom, located near inside the church, that can be utilized by sick children if necessary. Children who become ill will use the isolation bathroom and will be isolated in the office with isolation equipment.

LPAs observed a solid waste container with a tight-fitting lid and smoke/carbon monoxide detectors in both rooms. First aid supplies will be purchased and stored in both classrooms, inaccessible to children. Merat states that facility will not administer medications.

The food preparation area (kitchen) has hot and cold running water, sink, refrigerator, stove, dish washer, microwave, and storage space for food. Merat states that facility does not provide snacks and meals during pandemic time. Children will bring their own snacks and lunch.

There are 2 tables and 46 chairs. Drinking water will be provided indoors by pitchers of water and disposal cups. Transportation will not be provided by the Facility.

PRESCHOOL PLAYGROUND
(7.833 x 60) + (78.417 x 104) = 469.980 + 8155.368 = 8625.348
TOTAL PRESCHOOL OUTDOOR SPACE:
8625.348 sq. ft. divided by 75 = 115 children

Merat states that School-Age program will share Preschool playground, but at different time intervals. LPAs observed that the preschool playground is surrounded by appropriate fencing. Shade is provided by canopies. Drinking water will be provided outdoors by pitchers/disposable cups. LPAs did not observe any bodies of water during today's visit.

Report to be continued on Page #3

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: REHOBOTH PRESCHOOL/DAYCARE	FACILITY NUMBER: 434416304
	VISIT DATE: 03/30/2021

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
26
27
28
29
30
31
32

Report continued from Page #2

Incidental Medical Services (IMS) policy was discussed. Applicant was provided the information regarding ADA: toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: http://www.ada.gov/childqanda.htm. Annie states that the facility does not plan to provide IMS at this time.

Merat Ayalew, Applicant Representative and Director, has obtained a Criminal Records Clearance and Child Abuse Index Checks. Merat has met the education and experience qualification requirements and has completed the training on preventive health practices, which included pediatric cardiopulmonary resuscitation and pediatric first aid, one hour on Child Care Nutrition, and one hour on Lead Poisoning Prevention. Director has proof of immunity against Measles, Pertussis, and Influenza on file. Director's Mandated Reporter Training for Child Care Provider Certification expires 2/18/2023.

LPAs reminded Applicant of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the facility, 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 up to $3000.00 per person.

LPAs advised Merat that due to the current Covid-19 pandemic and "Shelter In Place" Order, the Evaluation Report will be emailed to her (email: meratayalew@gmail.com) with "Read Receipt" notification. Merat understands that her reply to the email will serve as acknowledgement that the report was received.

LPAs conducted an exit interview and advised Merat of the following items that needed to be completed and a follow-up inspection will be conducted.
1) Waiver request and playground schedules for School-age Program to share the Preschool yard.
2) Needs hooks in Room 5.
3) A divider in Room 5 to separate classroom and a break room.
4) Bathrooms need to be labeled Boys and Girls.
5) Room 4 should be setup and ready for school use.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3