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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416302
Report Date: 07/18/2024
Date Signed: 07/18/2024 07:38:48 PM

Document Has Been Signed on 07/18/2024 07:38 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:REHOBOTH PRESCHOOL/DAYCAREFACILITY NUMBER:
434416302
ADMINISTRATOR/
DIRECTOR:		MERAT AYALEWFACILITY TYPE:
850
ADDRESS:3275 WILLIAMS ROADTELEPHONE:
(408) 603-5251
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 38TOTAL ENROLLED CHILDREN: 38CENSUS: 31DATE:
07/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:01 PM
MET WITH:Telma RojasTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management-Other inspection. LPA met with Director Telma Rojas and explained the reason for the inspection. The purpose of this inspection is to discuss criminal record clearance and outdoor activity space.

During today's inspection, LPA observed that S-1 was present and was in the room with children. S-1 has cleared criminal record clearance, but fingerprints were not transferred to facility. Director filled out LIC 9182 during today's inspection. S-2 and S-3 were also present at the center. S-2 and S-3 is associated to the school-age program, but not the preschool.

LPA observed that areas around play structure does not have enough resilient material.

As a result of this inspection, Type A and Type B citation was issued. A civil penalty of $500 was assessed for caregiver background check. A notice of site visit has been issued and must remain posted for 30 days.

LPA Samantha Yip informed Director Telma Rojas that this report dated 07/18/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Director to provide a copy of this licensing report dated 07/18/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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 07/18/2024 07:38 PM - It Cannot Be Edited


Created By: Samantha Yip On 07/18/2024 at 04:19 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: REHOBOTH PRESCHOOL/DAYCARE
FACILITY NUMBER: 434416302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2024
Section Cited
CCR
101170(e)(2)

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Criminal Record Clearance. Request a transfer of a criminal record clearance as specified in Section 101170(f).
This requirement is not met as evidenced by:
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Director submitted LIC 9182 during today's inspection.
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Based on record review, S-1 has cleared criminal record clearance, but fingerprints were no transferred to facility. This poses an immediate health and safety risk to children in care.
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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/18/2024 07:38 PM - It Cannot Be Edited


Created By: Samantha Yip On 07/18/2024 at 04:20 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: REHOBOTH PRESCHOOL/DAYCARE
FACILITY NUMBER: 434416302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2024
Section Cited
CCR
101238.2(e)

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Outdoor Activity Space. As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls.
This requirement is not met as evidenced by:
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By POC 07/25/2024, facility will submit proof of purchase of additional resilient material. Upon installation of addtional resilient material, facility will
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Based on observation, the tan bark around the plastic structure is low, which poses a potential health and safety risk to children in care.
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submit proof.

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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
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