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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416303
Report Date: 07/25/2024
Date Signed: 08/07/2024 02:35:11 PM

Document Has Been Signed on 08/07/2024 02:35 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:
434416303
ADMINISTRATOR/
DIRECTOR:		MERAT AYALEWFACILITY TYPE:
830
ADDRESS:3275 WILLIAMS ROADTELEPHONE:
(408) 603-5251
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
07/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:Merat AyalewTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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This is an amended report.

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 facility was cited on 07/18/2024 for teacher qualifications and safe sleep. Present in the infant room were S-1, S-2, and six (6) infants.

S-1 has transcript on file, but there is no proof of completion of 3 semester units in infant care. S-2 has an international transcript which was not evaluated. Licensee Merat Ayalew stated that she will have her staff enroll in course. LPA informed Licensee that in order to be considered an infant teacher that the staff needs to complete 6 semester units, which includes 3 units in care of infant and be enrolled in at least 2 semester units each semester or quarter system until they have completed 12 semester units. Licensee stated that she will have S-3 be in the infant room. LPA reviewed S-3 file during today's inspection.

Licensee made the sheets on portable crib tight-fitted and submitted proof that sheets were purchased. LPA also observed that bottles and food container brought from home did not have the child's name and date on it. LPA also observed that food and bottles were in containers. There was a bottle of milk that was not in the refrigerator. There is a refrigerator in the kitchen that the infant program can use.

As a result of this inspection, Type A and Type B citations were issued as a result of this inspection. A civil penalty of $600 was assessed for failure to correct. Exit interview conducted and report was reviewed with Licensee Merat Ayalew.

LPA Samantha Yip informed Licensee Merat Ayalew 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 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
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 4
Document Has Been Signed on 07/25/2024 07:05 PM - It Cannot Be Edited


Created By: Samantha Yip On 07/25/2024 at 12:49 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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
101416.2(c)(1)(A)

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Infant Care Teacher Qualifications and Duties. At least three of the units required in (c)(1) above shall be related to the care of infants or shall contain instruction specific to infants.
This requirement is not met as evidenced by:
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By POC 07/26/2024, Licensee will submit updated staff schedule.
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Based on record review, S-1 and S-2 do not have proof of completion of 3 semester units in care of infant, which 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2024 07:05 PM - It Cannot Be Edited


Created By: Samantha Yip On 07/25/2024 at 12:54 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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2024
Section Cited
CCR
101427(j)

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Infant Care Food Service. 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:
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By POC 08/08/2024, facility will submit written plan on how they were ensure bottles, dishes, and containers of food brought from home are labeled
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Based on observation, bottles and containers of food brought by the infant's parent were not labeled with the child's name and date. All bottle and food containers are placed in a container that has the child's name. This poses a potential health and safety risk to children in care.
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with the child's name and date.
Type B
08/08/2024
Section Cited
CCR101227(a)(15)

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Food Services. All foods or beverages capable of supporting the rapid and progressive growth of microorganisms that can cause food infections or food intoxications shall be stored in covered containers at 45 degrees F (7.2 degrees C) or less.
This requirement is not met as evidenced by:
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By POC 08/08/2024, Licensee will submit written plan on how she will ensure that food and beverages will not support the rapid and
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Based on observation, LPA observed that there was a bottle of milk and food in the child's container, which poses a potential health and safety risk to children in care.
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progessive growith of microogranisms.
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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Document Has Been Signed on 07/25/2024 07:05 PM - It Cannot Be Edited


Created By: Samantha Yip On 07/25/2024 at 03:14 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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2024
Section Cited
CCR
101238.2(b)(1)

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Outdoor Activity Space. Provide a shaded rest area for the children.
This requirement is not met as evidenced by:
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By POC 08/08/2024, Licensee will submit proof of purchase of shaded area and will submit proof of installation once completed.
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Based on observation, there is no shaded area, which poses a potential 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


LIC809 (FAS) - (06/04)
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