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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701997
Report Date: 05/29/2024
Date Signed: 05/30/2024 08:23:56 AM

Document Has Been Signed on 05/30/2024 08:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ST. TIMOTHY'S CHRISTIAN PRESCHOOLFACILITY NUMBER:
430701997
ADMINISTRATOR/
DIRECTOR:		LORI THOMPSON-SAMUELFACILITY TYPE:
850
ADDRESS:5100 CAMDEN AVENUETELEPHONE:
(408) 265-0244
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 85TOTAL ENROLLED CHILDREN: 56CENSUS: 34DATE:
05/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Lori Thompson-SamuelTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 05/29/2024 at 12:33pm, Licensing Program Analyst (LPA), Farida Raja, conducted an unannounced case management inspection and met with Director, Lori Thompson-Samuel and explained purpose of visit.

Based on record review, facility does not have a designated fully qualified teacher during all operational hours in the absence of the Director. Staff responsible to act in Director’s absence as indicated on the Designation of Facility Responsibility (LIC 308) are not present all hours the center is in operation.

LPA conducted a facility walk though during today's inspection and observed a child using one stall in the bathroom and staff (S1) standing outside the bathroom door and not maintaining visual supervision. LPA reminded Director that in a childcare center no child shall be left without visual supervision by staff at any time. Based on staff interviews, staff stated that they have observed children using the restroom with staff positioned away from the restroom.

Two Type B deficiencies are being cited on the attached LIC 809D page. Appeal rights were provided to Director. Exit interview conducted and the report was reviewed with Director, Lori Thompson-Samuel.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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 05/30/2024 08:23 AM - It Cannot Be Edited


Created By: Farida Raja On 05/29/2024 at 02:52 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: ST. TIMOTHY'S CHRISTIAN PRESCHOOL
FACILITY NUMBER: 430701997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2024
Section Cited
CCR
101215.1(f)

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101215.1 Child Care Center Directors Qualifications and Duties (f) When the child care center director is absent... arrangements shall be made for a fully qualified teacher... to act as substitute. This substitute ... shall be designated as an authorized person to correct operational deficiencies that constitute immediate threats to children's health and safety.
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Director submitted an updated Personnel Report (LIC 500) and Designation of Facility Responsibility (LIC 308) during today's inspection. Deficiency was cleared during today's inspection.
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This requirement is not met as evidenced by: During record review LPA observed facility does not have a designated fully qualified teacher during all operational hours in the absence of the Director. Staff responsible to act in Director’s absence as indicated on the Designation of Facility Responsibility (LIC 308) are not present all hours the center is in operation.
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Type B
06/12/2024
Section Cited
CCR101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a)(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Director to submit a written plan of correction stating how staff will be trained to provide visual supervision to children at all times by plan of corretion date of 06/12/2024.
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This requirement is not met as evidenced by:
During facility walkthorugh LPA observed one child using one stall in the bathroom and staff (S1) standing outside the bathroom door and not maintaining visual supervision. Based on staff interviews, staff stated that they have observed children using the restroom with staff positioned away from the restroom.
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
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