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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502377
Report Date: 09/22/2022
Date Signed: 11/02/2022 04:32:05 PM

Document Has Been Signed on 11/02/2022 04:32 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CALVARY CROSS CHAPEL PRESCHOOLFACILITY NUMBER:
191502377
ADMINISTRATOR:ROBIN CLEMENTEFACILITY TYPE:
850
ADDRESS:16705 GRIDLEY ROADTELEPHONE:
5629243716
CITY:CERRITOSSTATE: CAZIP CODE:
90701
CAPACITY: 74TOTAL ENROLLED CHILDREN: 18CENSUS: 7DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Director, Robin ClementeTIME COMPLETED:
11:00 AM
NARRATIVE
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On September 22, 2022 at 8:00 am, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced inspection at the facility noted above and met with Director, Robin Clemente. The purpose of the inspection was to conduct the Required 1 Year inspection at the facility. Entrance Checklist – Child Care Centers (LIC 125) was provided to the Director upon arrival. The facility is currently licensed for a total of 74 preschool children. The facility is located on Calvary Cross Chapel premises. There is also a licensed school-age program located on site (License Number: 191598274). Per Director, the preschool program operates Monday through Friday from 6:30 am to 6:00 pm.

The Director guided LPA on a tour of the inside and outside of the facility. All areas on the facility sketch were inspected. The facility currently utilizes two (2) classrooms; Yellow Classroom and Purple Classroom. The facility also has two multipurpose rooms that are used by the children. Upon arrival, the following staff were present: Staff (S1) and Staff (S2) inside the Yellow Classroom with 7 children.

The following documents are posted in a prominent, publicly accessible area: Facility License, Menu, Child Passenger Restraint System Poster (PUB 269), Notification of Parents' Rights (LIC 393), Emergency Disaster Plan (LIC 610), Personal Rights (LIC 613A), and Daily Activity Schedule.

Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Children have their own cubby to store their belongings. Napping equipment (mats) were observed in the classrooms. Per Director, sheets are washed at the facility every Friday. Per Director, the isolation area is in the office. In the office, a mat can be placed on the floor for an ill child and the staff restroom is readily available if an ill child requires it. Age appropriate sinks and toilets were inspected for availability and good repair. General sanitation was observed. Availability of indoor drinking water was observed in each classroom.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Monique Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 11/02/2022 04:32 PM - It Cannot Be Edited


Created By: Monique Ayala On 09/22/2022 at 09:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CALVARY CROSS CHAPEL PRESCHOOL
FACILITY NUMBER: 191502377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 personnel records (Director, S1, and S2) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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Director will ensure that staff will renew their Mandated Reporter training, and submit proof of completion to LPA via e-mail by October 24th.
Type B
Section Cited
CCR
101215.1(m)
Child Care Center Director Qualifications and Duties
(m) A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the Director did not have proof of completion for the Preventative Health and Safety Practices which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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Director will complete the Preventative Health and Safety Practices course (EMSA-approved), and submit proof of completion to LPA via e-mail by October 24th.
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:Valarie Cook
LICENSING EVALUATOR NAME:Monique Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/02/2022 04:32 PM - It Cannot Be Edited


Created By: Monique Ayala On 09/22/2022 at 09:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CALVARY CROSS CHAPEL PRESCHOOL
FACILITY NUMBER: 191502377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff records (S2) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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Director will obtain a completed Health Screening Report (LIC 503) for S2, and submit a copy to LPA via e-mail by October 24th.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 children's records (C5) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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Director will obtain a completed Physician's Report (LIC 701) for C5, and submit a copy to LPA via e-mail by October 24th.
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:Valarie Cook
LICENSING EVALUATOR NAME:Monique Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


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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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CALVARY CROSS CHAPEL PRESCHOOL
FACILITY NUMBER: 191502377
VISIT DATE: 09/22/2022
NARRATIVE
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The facility has smoke detectors and a carbon monoxide detector that were tested by the Director and are operable. The fire extinguishers are fully charged and were last serviced on April 20, 2022. The facility has verification of disaster and fire drills available for review. The last drill was conducted on June 15, 2022. First Aid supplies were observed and kept in the kitchen and outdoor play yard.

Disinfectants, cleaning solutions, and other items that are hazardous to children, were made inaccessible to children in all areas. Director confirmed that there are no poisons stored at the facility. All kitchen, food preparation and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. All storage containers for solid waste have tight-fitting covers that are kept on and in good repair. LPA observed electrical outlet covers installed in all child care areas.

Outdoor playground equipment is in a safe condition, free of sharp, lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, slides, and similar equipment are cushioned with material that could absorb a fall. There is adequate shade in the outdoor play yard. Availability of outdoor drinking water was observed. No bodies of water were observed on the premises.

All individuals present have obtained a criminal record clearance or criminal record exemption. Director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA conducted a record review of five (5) children’s records and three (3) personnel records for completeness. Based on the record reviews, one (1) child (C5) did not have the Physician's Report (LIC 701) available for review. Based on record reviews, 3 personnel (Director, S1 and S2) did not have a current Mandated Reporter Training Certificate available for review. LPA also found that the Director did not have a certificate of completion for Preventative Health and Safety Practices (EMSA-approved) and S2 did not have a Health Screening Report (LIC 503) available for review. All staff present have a current Pediatric First Aid and CPR certification. The names of children and staff whose records were reviewed were documented.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Monique Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CALVARY CROSS CHAPEL PRESCHOOL
FACILITY NUMBER: 191502377
VISIT DATE: 09/22/2022
NARRATIVE
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Children's roster was reviewed and is current. Sign-in and sign-out sheets were reviewed; all children present were signed in. Per Director, transportation is not provided by the facility for the preschool program. The facility provides the children with morning and afternoon snacks. Per Director, children bring their own lunch each day from home. During the inspection, snacks were reviewed for availability and quantity. According to the Director, medication is only administered to a child when accompanied with a doctor's note and medication is stored in a cabinet located in the classroom. At this time, no children enrolled in care require any medication.

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/childqanda.htm.

LPA advised the Director on how to access forms, regulations, quarterly updates, and Provider Information Notices (PINs) on the Department website at: www.ccld.ca.gov.

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.

Deficiencies were cited during today's inspection (refer to deficiency pages).

A Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days.

Exit interview was conducted and report was reviewed with Director, Robin Clemente. Appeal Rights were discussed, and a copy was provided to the Director.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Monique Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
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