430710384-12-11-2023-07-CC-FRAA-CYEN2D-20231211090434

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430710384
Report Date: 12/08/2023
Date Signed: 12/11/2023 09:04:56 AM

Document Has Been Signed on 12/11/2023 09:04 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:	CALVARY CHAPEL CHRISTIAN SCHOOL		FACILITY NUMBER:	430710384
ADMINISTRATOR:	MELINDA TIOPAN		FACILITY TYPE:	850
ADDRESS:	1175 HILLSDALE AVENUE		TELEPHONE:	(408) 269-2222
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY: 90	TOTAL ENROLLED CHILDREN: 40	CENSUS: 29	DATE:	12/08/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Amanda Arellano		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/08/2023 at 8:25am, Licensing Program Analyst (LPA), Farida Raja, met with Director, Amanda Arellano, for an unannounced Required 3-Year inspection in the preschool program and explained the nature of today's inspection. The facility is licensed to serve children ages 2 years to entry into first grade in 9 rooms. Director stated that only Rooms C105, C106 and C107 are in use at present. Director will submit an updated facility sketch (LIC 999) to LPA by 12/22/2023. LPA observed the required posted materials in the front office. Menus, emergency disaster plan (LIC 610) and daily activity schedule were observed posted in each classroom. Days and hours of operation are Monday through Friday, 7:30 am to 5:30 pm. LPA and Director toured the indoor and outdoor areas of the preschool program and observed the following ratios: Room 5 (C105)- 5 children: 2 teachers Room 6 (C106)- 8 children : 1 teacher Room 7(C107)- 6 children : 1 teacher Facility was in compliance with teacher to children ratio requirement. The classrooms, children's restrooms, staff restrooms and kitchens were inspected. Children were engaged in various activities under the visual supervision of teachers. Facility has central heating/cooling for comfort of children. Director states that there are no weapons or firearms on the premises. There is a working telephone at the facility (408-269-2222). Disinfectants, cleaning products and medicines, were stored in the mini kitchens attached to each classroom, inaccessible to the children in care. All cabinets, drawers, and closets used for storage were child locked. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. Floors were clean and free from tripping hazards. Emergency bags and first aid supplies were observed in each classroom. Continued on Page 2

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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 12/11/2023 09:04 AM - It Cannot Be Edited

Created By: Farida Raja On 12/08/2023 at 12:00 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: CALVARY CHAPEL CHRISTIAN SCHOOL	FACILITY NUMBER: 430710384
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1596.871(c)(1)(A)

Administration of Child Day Care Licensing

Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review and interview, the licensee did not comply with the section cited above for one staff (S4) which poses an immediate health, safety or personal rights risk to persons in care. On review of facility roster, LPA observed one staff's (S4) fingerprints are 'in process' and not cleared.
	POC Due Date: 12/09/2023
	Plan of Correction
1 2 3 4	Director will submit a written Plan of Correction to LPA by 12/09/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 12/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 12/11/2023 09:04 AM - It Cannot Be Edited

Created By: Farida Raja On 12/08/2023 at 12:00 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: CALVARY CHAPEL CHRISTIAN SCHOOL	FACILITY NUMBER: 430710384
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101226(e)(3)(A)

Health-Related Services

(3) Prescription medications may be administered if all of the following conditions are met: (A) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on obervation, record review and interview, the licensee did not comply with the section cited above for children, C1 and C2, which poses a potential health, safety or personal rights risk to persons in care. LPA observed two children's (C1 and C2) medications were not in their original container with a label indicating the child's name, date and dosage.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Director will obtain medication in original containers with unaltered labels from parent/authorized representatives of child, C1 and C2 and submit a Plan of Correction to LPA by 12/22/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 12/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CALVARY CHAPEL CHRISTIAN SCHOOL	FACILITY NUMBER: 430710384
	VISIT DATE: 12/08/2023

NARRATIVE

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Napping mats were observed to be appropriate and labelled with each child's name. LPA observed solid waste containers with tight-fitting lids in all classrooms. Restrooms and sinks for children were observed to be safe, sanitary, and in working condition.

LPA observed fire extinguishers, working smoke and carbon monoxide detectors, and fire pull stations in classrooms. Log shows that the last Fire Drill was conducted on 11/01/2023 which is compliant with the six-month requirement for facilities.

Drinking water is readily available for children in each room and in the outdoor playground area via water pitchers and disposable cups. Water lead testing was completed for the facility on 02/11/2023 and no Action Level Exceedances were reported. Director provided a copy of the water lead test report, LIC 9275, LIC 9276 and facility sketch indicating the water outlets tested during today's visit. Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Director stated that the facility provides snacks. Parents provided lunch for children. Foods and beverages were stored safely to prevent contamination and spoilage. Food storage and preparation areas were observed to be sanitary. All food and beverages that require refrigeration are stored in covered containers.

Outdoor playground and play equipment was inspected and observed to be fenced in and free of hazards. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (tankbark) to absorb falls. Areas around and under high climbing equipment, slides and swings were cushioned with resilient material. Shaded rest area is provided by canopies. LPA observed a covered sand box in both playgrounds inspected. There were no bodies of water observed.

Children sign in and out procedures and logs were reviewed. Children's roster was reviewed. Director will email a copy of the roster to LPA. LPA reviewed six (6) children's files during today's inspection. Each child's file reviewed contained the required forms.

Continued on Page 3

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: CALVARY CHAPEL CHRISTIAN SCHOOL	FACILITY NUMBER: 430710384
	VISIT DATE: 12/08/2023

NARRATIVE

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Director provided a copy of the updated Emergency Disaster Plan (LIC 610) and Personnel Report (LIC 500) during today's inspection. LPA reviewed five (5) staff files. Director, Amanda Arellano provided a copy of the director packet to LPA. All staff files reviewed contain the required transcripts/verification of experience. All staff on site have a current CPR and First Aid certification. Director 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). All staff have the required immunization's against pertussis, measles and statement declining the influenza vaccine. LPA also observed the required Mandated Reporter Training on file for all staff. On review of facility roster, LPA observed one staff's (S4) fingerprints are 'in process' and not cleared.

Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Director stated that facility does handle medications and currently has children in care who require Incidental Medical Services. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. Facility has an approved IMS Plan on file with San Jose Regional Office. LPA observed two children's (C1 and C2) medications were not in their original container with a label indicating the child's name, date and dosage. Isolation of sick child was discussed, and Director explained that sick children will be isolated in the director's office and isolation equipment will be provided. A staff restroom which is off limits to other children is used if necessary. Child is always under visual supervision while in care of the facility.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Facility does not provide transportation to children, but Director understands that children cannot be left alone, unattended in parked vehicles.

Continued on Page 4

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: CALVARY CHAPEL CHRISTIAN SCHOOL	FACILITY NUMBER: 430710384
	VISIT DATE: 12/08/2023

NARRATIVE

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Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process

One Type A and one Type B deficiency was cited today on the attached LIC 809D pages. Appeal rights and LIC 9224 were printed and given to Director. Due to the issuance of a Type A Citation, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to any newly enrolled parents/guardians enrolled over the next 12 months from the date of this report. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file. LPA reminded Director that failure to correct deficiencies by Plan of Correction Due Date may result in penalties of $100 per day per violation.

Exit interview conducted and report was reviewed with Director, Amanda Arellano.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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