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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416302
Report Date: 07/25/2024
Date Signed: 07/25/2024 07:04:15 PM

Document Has Been Signed on 07/25/2024 07:04 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:
07/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:01 AM
MET WITH:Merat AyalewTIME VISIT/
INSPECTION COMPLETED:
11:59 AM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Plan of Correction (POC) inspection. LPA met with Licensee Merat Ayalew and explained the reason for the inspection. The purpose of this inspection is facility was cited on 07/18/2024 for ratio, personal rights, supervision, limitation of capacity, building and grounds, and outdoor activity space. Present during today's inspection were 31 children, at least six staff, and two therapist.

During today's inspection, LPA conducted observation and inspected the physical plant. LPA also reviewed staff files. Room 1 had 15 children with three staff, S-1, S-2, and S-3, and Room 2 had 16 children with three staff, S-4, S-5, and S-6. Licensee understands that any international transcripts need to be evaluated to show the school is accredited and the number of units. LPA did not observe any school-age children and preschool children commingled during today's inspection.

At 10:48AM and 11:51AM, LPA observed that a staff grabbed a child's arm.

At 1:45PM, LPA observed that there were two children in Room 2. There was staff present in the room. LPA observed that staff were walking back and forth from either the kitchen area or Room 1.

LPA inspected the outdoor activity space. A board was installed on the play structure that had a gap on the top. Licensee placed tape on the broken part of the plastic structure during today's inspection. Admin submitted proof of receipt that additional tan bark was purchased and invoice for when pest control came out.

---------------------continues on 809 dated 07/25/2024 page 2--------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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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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: REHOBOTH PRESCHOOL/DAYCARE
FACILITY NUMBER: 434416302
VISIT DATE: 07/25/2024
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This is an amended report.

----------------CONTINUATION OF 809 DATED 07/25/2024 PAGE 1-------------

LPA observed that S-5 and S-6 were associated to school-age license, but not to the preschool license. Licensee submitted LIC 9182 during today's inspection as well for S-7.

As a result of this inspection, Type A citations were issued. Civil penalties of $600 was assessed for repeat violation. Exit interview conducted and report was reviewed with Licensee Merat Ayalew. A notice of site visit has been issued and must remain posted for 30 days.

LPA Samantha Yip informed Licensee Merat Ayalew that this report dated 07/18/2024 documents two Type A citations 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 Licensee to provide a copy of this licensing report dated 07/25/2024 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: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2024 10:21 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/07/2024 01:19 PM


Created By: Samantha Yip On 07/25/2024 at 02:19 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
CCLD Regional Office, 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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
101223(a)(3)

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Personal Rights. The licensee shall ensure that each child is accorded the following personal rights: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
This requirement is not met as evidenced by:
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By POC 07/26/2024, facility will submit plan on how they will ensure that children's personal rights are not violated and conduct training with staff.
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Based on observation, at 10:48AM, LPA observed a staff grab a child by their arm, which poses an immediate health and safety risk to children in care.
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Type A
07/26/2024
Section Cited
CCR101229(a)(1)

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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time,... Supervision shall include visual observation.
This requirement is not met as evidenced by:
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By POC 07/26/2024, Licensee will submit plan on how she will ensure children are supervised at all times.
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Based on observation, at 1:45PM, there were two children in Room 2. Staff were walked into Room 1 to get water, then back into Room 2. The door between the room was open. 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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


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