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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416304
Report Date: 04/06/2021
Date Signed: 05/21/2021 06:26:57 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/DAYCAREFACILITY NUMBER:
434416304
ADMINISTRATOR:MERAT AYALEWFACILITY TYPE:
840
ADDRESS:3275 WILLIAMS ROADTELEPHONE:
(408) 603-5251
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:40CENSUS: 0DATE:
04/06/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Merat Ayelew, Applicant RepresentativeTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Mel Matos and Dung Mac conducted an announced follow up pre-licensing inspection via video conference call (FaceTime) with Merat Ayalew, Applicant Representative, today. The initial prelicensing inspection was completed on March 30, 2021 and the purpose of today's follow up tele-inspection was to complete the prelicensing process. The Facility is applying for a preschool license for 40 school-age children in Room 4 & 5.

LPAs inspected Rooms 4 & 5 during today's tele-inspection. LPAs observed that Room 4 is clean. Cleaning compounds, medications, sharp objects, and similar items were not observed in Room 4. A divider in Room 5 was not setup.

LPAs conducted an exit interview and advised Merat of the following items that needed to be ready prior to a 2nd follow-up inspection.
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".
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
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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