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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417157
Report Date: 05/01/2026
Date Signed: 05/01/2026 11:43:11 AM

Document Has Been Signed on 05/01/2026 11:43 AM - 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:CYPRESS CHRISTIAN ACADEMYFACILITY NUMBER:
434417157
ADMINISTRATOR/
DIRECTOR:		MARY SUSANNA TALATHOTIFACILITY TYPE:
860
ADDRESS:460 CYPRESS AVENUETELEPHONE:
(408) 597-4975
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 34TOTAL ENROLLED CHILDREN: 7CENSUS: 6DATE:
05/01/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Mary Susanna TalathothiTIME VISIT/
INSPECTION COMPLETED:
11:52 AM
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Licensing Program Analyst (LPA), Deanna Villagrana, conducted an unannounced annual/random inspection to the Facility today. LPA met with director, Mary Susanna Talathothi and explained the nature of today's visit to her. The facility is licensed at a church site, Christ Church of India. The playground area of the Facility is located to the back and right side of the facility.

LPA toured the Facility both inside and outside for today's inspection. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law, Menus, and Activity Schedule.

A review of staff records on 04/20/2026 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions Director Mary Susanna Talathothi was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA reviewed seven children's and four staff (1 director, 1 teacher, 2 aides) files during today's inspection. Children were missing LIC627. Director and two staff did not have a current mandated reporter certificate on file. Two staff were missing immunization records against measles. Staff 4 is missing LIC503. LPA observed all staff have a current CPR and First Aid certifications on file. Staff files (director and 1 teacher) reviewed contain the required transcripts/verification of experience. Mary understands 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 (field trips).

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Deanna Villagrana
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2026
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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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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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: CYPRESS CHRISTIAN ACADEMY
FACILITY NUMBER: 434417157
VISIT DATE: 05/01/2026
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LPA discussed the safe sleep regulations with licensee Mary Susanna Talathothi and 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 Mary Susanna Talathothi 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.

LPA observed that the teacher/child ratio was in compliance during today's visit. LPA observed two preschool children with one teacher in the community play room. Four additional children and one aide arrived during visit. Mary understands the conditions, limitations, and capacity specifications of the facility and understands that children shall be visually supervised at all times. LPA observed that all rooms are clean and safe for all children and staff. Mary states that the Facility staff clean daily on a weekly basis and have a janitorial service that comes in Sunday nights and deep cleans the facility. Children bring there own drinking water from home in a water thermos and have a water dispenser to refill if necessary. LPA observed solid waste containers with tight-fitting lids in the Facility. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff toilet not utilized by the children which an isolated child can use if needed. Mary states that there are no weapons or firearms on the premises.



The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. Children bring their own lunch from home and facility provides morning and afternoon snacks. Cleaning supplies and poisons are inaccessible to the children and stored in a storage closet inaccessible to children. Any medications at the Facility are stored in the director's office area. No IMS is administered by the Facility.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. An umbrella is used near the sand box and a large tent is used in the open space area of the playground. LPA did not observe any bodies of water.
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Deanna Villagrana
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CYPRESS CHRISTIAN ACADEMY
FACILITY NUMBER: 434417157
VISIT DATE: 05/01/2026
NARRATIVE
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Exit interview conducted and report was reviewed with the licensee Mary Susanna Talathothi.


The following type B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.



A notice of site visit was given and must remain posted for 30 days. Appeal Rights were provided.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Deanna Villagrana
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/01/2026 11:43 AM - It Cannot Be Edited


Created By: Deanna Villagrana On 05/01/2026 at 11:21 AM
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: CYPRESS CHRISTIAN ACADEMY
FACILITY NUMBER: 434417157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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. Director and two staff did not have a current mandated reporter certificate on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Director will submit a current Mandated Reporter training certificate for herself and two other staff to CCLD by POC date. Training can be found at www.mandatedreporterca.com
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. Two staff were missing immunization records against measles which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Director will submit immunization records against measles for two staff to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susy Cervantes
NAME OF LICENSING PROGRAM MANAGER:
Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/01/2026 11:43 AM - It Cannot Be Edited


Created By: Deanna Villagrana On 05/01/2026 at 11:21 AM
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: CYPRESS CHRISTIAN ACADEMY
FACILITY NUMBER: 434417157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2026

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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4
Based on record review, the licensee did not comply with the section cited above. Staff 4 is missing LIC503 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Director will submit LIC503 for staff 4 to CCLD by POC date.
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.
Susy Cervantes
NAME OF LICENSING PROGRAM MANAGER:
Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2026


LIC809 (FAS) - (06/04)
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