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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354403579
Report Date: 08/18/2022
Date Signed: 08/18/2022 01:23:52 PM

Document Has Been Signed on 08/18/2022 01:23 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SACRED HEART PARISH PRESCHOOLFACILITY NUMBER:
354403579
ADMINISTRATOR:CONNIE LEE BUMATAYFACILITY TYPE:
850
ADDRESS:670 COLLEGE STREETTELEPHONE:
(831) 637-4157
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 36TOTAL ENROLLED CHILDREN: 27CENSUS: 0DATE:
08/18/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Connie Lee BumatayTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA), Deanna Villagrana, conducted an unannounced annual/random inspection to the Facility today. LPA met with director, Connie Lee Bumatay and explained the nature of today's visit to her. The Facility is closed and will open on 08/22/2022. LPA did not observe any children. The Facility is licensed in room 428 and 428 at Sacred Heart Parish School. The playground area of the Facility is located to the right of the classroom.

LPA toured the Facility both inside and outside for today's inspection. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law, Menus, and Activity Schedule.

A review of staff records on 08/16/2022 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions Director Connie Lee Bumatay 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 reviewed five children's and four staff (1 director & 3 teachers) files during today's inspection. Staff 4 is missing Health screening. Staff 4 is missing TB test. Staff 4 is missing MMR immunization. Three staff have current CPR and First Aid certifications on file. Teachers reviewed contain the required transcripts/verification of experience. Connie Lee Bumatay understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips).
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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Document Has Been Signed on 08/18/2022 01:23 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 08/18/2022 at 12:20 PM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SACRED HEART PARISH PRESCHOOL
FACILITY NUMBER: 354403579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record, the licensee did not comply with the section cited above. Staff 4 is missing MMR immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
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Director will submit MMR immunization for staff 4 to CCLD by POC date.
Type B
Section Cited
CCR
101216(l)(1)(B)
Personnel Requirements
(B) A copy of the signed LIC 9052 (11/94) shall be kept in the employee's personnel record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above. Staff 4 is missing Health screening which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
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Director will submit Health Screening for staff 4 to CCLD by POC date.
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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2022 01:23 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 08/18/2022 at 12:20 PM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SACRED HEART PARISH PRESCHOOL
FACILITY NUMBER: 354403579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above. Staff 4 is missing TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
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Director will submit a current TB test that was completed within 1 year of hire to CCLD by POC date.
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.
SUPERVISOR'S NAME:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022


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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SACRED HEART PARISH PRESCHOOL
FACILITY NUMBER: 354403579
VISIT DATE: 08/18/2022
NARRATIVE
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Connie understands the conditions, limitations, and capacity specifications of the Facility license and understands that children shall be visually supervised at all times. LPA observed that both rooms are clean and safe for all children and staff. Connie states that the Facility is cleaned by an outside janitorial service. Children bring their own water containers and a water dispenser is available to refill containers. LPA observed solid waste containers with tight-fitting lids in the Facility. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff toilet not utilized by the children which an isolated child can use if needed. Connie states that there are no weapons or firearms on the premises.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. Cleaning supplies are inaccessible to the children and stored on high shelves or closet inaccessible to children. Any poisons are stored in high shelves in closets. Any medications at the Facility are stored in closet on high shelves. No IMS is administered by the Facility.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. LPA observed the playground has enough resilient material (solid rubber surface) in the playground area. A tarp and patio provide shade for the day care children. LPA did not observe any bodies of water.

Exit interview conducted and report was reviewed with the Director Connie Lee Bumatay.


The following type B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
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