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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416304
Report Date: 04/13/2021
Date Signed: 05/21/2021 06:26:16 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:
04/13/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Merat Ayalew, 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 pre-licensing inspection was completed on March 30, 2021 and the purpose of today's follow up tele-inspection was to complete the pre-licensing process. The Facility is applying for a preschool license for 40 school-age children in Rooms 4 & 5.

Merat informed LPAs that Rooms 4 & 5 will be used as regular classrooms. LPAs inspected Classrooms 4& 5 and bathrooms during today's tele-inspection. LPAs observed a first kit in Room 4, inaccessible to children. A divider in Room 5 was setup. LPAs observed 8 tables, 80 chairs, and 80 hooks. There are 5 sinks (75), 3 toilets and 1 urinal (60) available for school-age children. Both bathrooms (boys & girls) provide individual privacy for the school-age children. Merat stated that hot water is available in the children's sinks and understands that hot water temperature should not be more than 120 degrees. Waiver request for School-age Program to share the Preschool yard was received.

LPAs conducted an exit Interview and advised Merat that a license for 40 School-age children will be submitted for the final stage of review by Licensing Management upon the receipt of the staggered schedules for the shared playground.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021
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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