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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416304
Report Date: 07/25/2024
Date Signed: 07/25/2024 05:05:02 PM

Document Has Been Signed on 07/25/2024 05:05 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:
434416304
ADMINISTRATOR/
DIRECTOR:		MERAT AYALEWFACILITY TYPE:
840
ADDRESS:3275 WILLIAMS ROADTELEPHONE:
(408) 603-5251
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 38TOTAL ENROLLED CHILDREN: 38CENSUS: 17DATE:
07/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Merat AyalewTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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 limitation of capacity and criminal record clearance and to amend the report from 07/18/2024. There were 17 school-age children, one staff, and one volunteer. Facility was not within ratio during today's inspection.

During today's inspection, LPA did not observed the school-age children using the grass area and patio area that is in-between the church and the preschool yard.

LPA observed at 12:08PM that the volunteer was left alone with 8 children in the hallway. LPA discussed with Licensee that volunteers cannot be left alone with children.

At 1:49PM, LPA observed that S-1 and S-2 were with the school-age children. S-1 has an international transcript, which was not evaluated. S-2 does not have transcript on file.

The center will submit the following by 08/08/2024:
- updated LIC 999

As a result of this inspection, Type A citations were issued. A civil penalty of $400 was assessed for failure to correct. 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
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 07/25/2024 05:05 PM - It Cannot Be Edited


Created By: Samantha Yip On 07/25/2024 at 02:36 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: 434416304

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
101170(b)(4)(D)

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Criminal Record Clearance. A student who is enrolled or participating at an accredited educational institution if all of the following apply: The student is not left alone with the children in care.
This requirement is not met as evidenced by:
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By POC 07/26/2024, facility will submit written plan on how they will ensure volunteer is not left alone with children and staff schedule.
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Based on observation, LPA observed that the volunteer was outside the bathroom with children alone. This poses an immediate health and safety risk to children in care.
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Type A
07/26/2024
Section Cited
CCR101516.5(b)(1)

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Teacher-Child Ratio. A teacher shall supervise no more than 14 children or with an aide a maximum of 28 children.
This requirement is not met as evidenced by:
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By POC 07/26/2024, facility will submit staff schedule.
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Based on observation, there were 17 children with one staff. 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


LIC809 (FAS) - (06/04)
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