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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416303
Report Date: 04/29/2025
Date Signed: 04/29/2025 02:31:27 PM

Document Has Been Signed on 04/29/2025 02:31 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:REHOBOTH PRESCHOOL/DAYCAREFACILITY NUMBER:
434416303
ADMINISTRATOR/
DIRECTOR:		DINORA SANCHEZFACILITY TYPE:
830
ADDRESS:3275 WILLIAMS ROADTELEPHONE:
(408) 603-5251
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
04/29/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Merat AyalewTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Licensee, Merat Ayalew, for an unannounced Annual/Random Inspection. LPA was granted access to the facility by the Licensee and toured both indoors and outdoors during the inspection. Upon arrival, there were 3 children (infant-age) and 2 staff (1 teacher/ 1 assistant) present, which is compliant with the facility license capacity and ratio requirements. LPA observed all required postings near the entrance to the facility. Hours of operation for the facility are Monday – Friday, 6:45AM-06:00PM. There are no active waivers

Licensee 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. All staff present had criminal record clearance and were associated to the roster on Guardian.

LPA reviewed sign-in/out sheets, facility roster (LIC9040), and fire/disaster drill log during today’s inspection. Sign-in/out was observed to be completed with full legal signature and time of day. The last fire/disaster drill was conducted on 12/19/2024, which is compliant with the six month requirement for facilities. LPA observed a fully charged 3A40BC fire extinguisher last serviced 02/18/2021, which is not compliant with state fire marshal regulations. LPA observed a fully functioning smoke detector system and a working carbon monoxide detector.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/29/2025 02:31 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 04/29/2025 at 12:15 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: 434416303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101430(a)(3)(A)(4)
Infant Care Activities
(A) Staff shall place infants up to 12-months of age on their backs for sleeping. (4) Infants with an Individual Infant Sleeping Plan [LIC 9227 (3/20)] that have Section C of the form completed and signed by an authorized representative shall be placed on their back when first laid down to sleep. In the event the infant changes position, the infant may remain in the alternative position.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Director to email proof that LIC9227 is complete for all children that have been enrolled at the age of less than 12 months. Director to provide a written plan how to fill out LIC9227 and implement it into enrollment packet so all children enrolled under 12 months old have a completed LIC9227 or it is started and updated as the child's developmental stages progress.
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 review, the licensee did not comply with the section cited above in 3 out of 3 staff files did not have immunizatio records on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Director to provide proof of immunization records showing immunization to MMR, TDAP for infant teacher and aides.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2025 02:31 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 04/29/2025 at 12:15 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: 434416303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff files did not have a Negative TB test on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Director to forward photographic proof that staff person has a negative TB test on file.
Type B
Section Cited
CCR
101419.2(a)
Infant Needs and Services Plan
(a) Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 files did not have an updated Needs and Services Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Director to update the Needs and Services plan for all infants in care under one year of age. Director to submit a written plan how she will insure that the Infant Needs and Services plan is updated for all infants during the ages of 0-12 months while in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2025 02:31 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 04/29/2025 at 12:15 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: 434416303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(b)(2)
Infant Needs and Services Plan
(b) The needs and services plan shall be in writing and shall include the following: (2) Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan [LIC 9227 (3/20)], which is incorporated by reference.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 files did not have a completed LIC9227 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Director to review all LIC9227 and complete them as necessary. Director to provide a written plan as to how to track and complete LIC9227 as infants developmental stage determines.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 children did not have a Physician's report which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Director to insure that all children in care have a completed Physician's report within one month of enrollment or sooner. Director to provide a written plan how she will insure that all children in care have a current physician's report on file within one month of enrollment and prior to admission to the day care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 04/29/2025 02:31 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 04/29/2025 at 12:15 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: 434416303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(b)(2)
Child's Medical Assessments
(b) The medical assessment shall provide the following: (2) Results of a test for tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 4 children's files was missing a negative TB test or TB assessment by a physician which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Director to follow up with parents to collect a negative TB test or TB Assessment and provide photographic proof to LPA. Director to provide a written plan how she will ensure that a Negative TB Test or Assessment is collected within one month of enrollment and prior to admissions of the day care.
Type B
Section Cited
CCR
101220.1(a)
Immunizations
(a) Prior to admission to a child care center, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, commencing with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 children's files did not have immunization records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Director to follow up with parents to collect current immunization records and provide photographic proof to LPA. Director to provide a written plan how she will ensure that immunization records are collected within one month of enrollment and prior to admissions of the day care. This plan will also incude how immunization records will be regularly to insure all updated immunization records are tracked.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 04/29/2025 02:31 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 04/29/2025 at 12:15 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: 434416303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101427(j)
Infant Care Food Service
(j) Bottles, dishes and containers of food brought by the infant's authorized representative shall be labeled with the infant's name and the current date.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 objects as LPA observed two jars with food, no label with children's names which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Director to train staff to insure they only accept food from home that is labeled with child's name. Director to train staff that each child must have their own utensils and they cannot be shared between children. Director to email LPA a written statement of the training completed and a plan to insure that food safety is handled in accordance to written directives.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 7 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: REHOBOTH PRESCHOOL/DAYCARE
FACILITY NUMBER: 434416303
VISIT DATE: 04/29/2025
NARRATIVE
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Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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/.

Indoor areas of the facility were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom, not utilized by staff. The Licensee states a working landline is designated for the facility, however most parents speak directly with the licensee through her cell phone. Cleaning and maintenance for the facility is conducted by staff people during the school hours along with deeper cleaning before and after the facility is open. The Licensee states that there are no weapons or firearms on the premises.

Infant Safe Sleep regulations (PIN 20-24-CCP) were discussed with the Licensee, including the Individual Infant Sleeping Plan (LIC9227). LPA reminded Licensee that infants up to 12 months of age should be placed on their back to sleep, that cribs should be free of all loose articles and hanging objects, and that infants should not be swaddled. Infants should be supervised while sleeping and documentation of sleep checks every 15 minutes should remain in the infant’s file. Documentation should include the time of the check, the infant’s physical condition, and initials of the staff member checking on the infant. LPA discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Continued on Page 3
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: REHOBOTH PRESCHOOL/DAYCARE
FACILITY NUMBER: 434416303
VISIT DATE: 04/29/2025
NARRATIVE
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The outdoor area of the facility was inspected and observed to be fenced in. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (rubber padding) to absorb falls. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by umbrella and building overhang.

Food is provided by the facility and is stored, prepared, and served in a safe and healthful manner to the children. Facility offers full day program and provides (midmorning snack, midafternoon snack, and lunch) to children that do not bring food from home. Menu is in writing and posted at least one week in advance, accessible to authorized representatives. The kitchen and storage area is clean and free of litter and rubbish. Equipment necessary for the storage, preparation and service of food is well maintained, clean, and sanitized after each use. Drinking water is readily available for children in the facility via water pitchers and water bottles from home labeled with the children’s names.

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 on 02/26/2024 in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

4 children’s files (infants) were reviewed during today’s inspection for the following records: Physician’s Report (LIC701), Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Signed Admission Agreement, and Immunization Records (PM286). When reviewing infant’s files, LPA observed Individual Infant Sleep Plan (LIC9227) was incomplete, Infant needs and services plans were outdated. Infant sleep log was complete for all infants in care.

Continued on page 4
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: REHOBOTH PRESCHOOL/DAYCARE
FACILITY NUMBER: 434416303
VISIT DATE: 04/29/2025
NARRATIVE
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2 staff files (1 teacher/ 1 aide) were reviewed for the following records: Transcripts/Verification of Experience, Health Screening Report (LIC503), Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, Tuberculosis (TB) Clearance, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). There is at least one staff member present with current CPR/First-Aid that expires 08/09/2026. All staff present had current Mandated Reporter Training that was valid. LPA reminded Licensee that the Mandated Reporter Training must be renewed by all staff every 2 years.

The Licensee understands that the site director shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. Licensee stated the Director was out sick today and had been sick yesterday as well. LPA reminded Licensee 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, such as field trips.

As a result of today's inspection, deficiencies have been cited. More information provided on the attached LIC809-D pages. Exit interview conducted with Licensee, Merat Ayalew. Report reviewed and provided along with appeal rights.

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

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.
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
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