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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010205821
Report Date: 01/07/2022
Date Signed: 01/07/2022 11:08:50 AM

Document Has Been Signed on 01/07/2022 11:08 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:VALLEY CHRISTIAN PRESCHOOLFACILITY NUMBER:
010205821
ADMINISTRATOR:JARIN, RINAFACILITY TYPE:
850
ADDRESS:7500 INSPIRATION DRIVETELEPHONE:
(925) 560-6235
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 132TOTAL ENROLLED CHILDREN: 132CENSUS: 42DATE:
01/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rina JarinTIME COMPLETED:
11:30 AM
NARRATIVE
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On 1/7/2022 at 9:00am Licensing Program Analysts (LPAs) Jaylena Miller and Christina Uribe conducted a subsequent case management inspection.

LPAs reviewed an email that was sent to preschool parents on 12/20/2021 revealing a positive COVID and those who were present on 12/15/2021 and 12/17/2021 were “possibly exposed”. LPAs checked FAS and the facility did not report an Unusual Incident Report for the positive COVID on 12/20/2021. As a result, and Per California Code of Regulations, Title 22, Division 12, Chapter 1 Section 101212(d)(1)(E) is being cited. Please see LIC 809-D for deficiency.

Exit interview conducted. Notice of site visit given and must be posted for 30 days. A copy of this report and appeal rights were given to director, Rina Jarin.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jaylena Miller
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
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 01/07/2022 11:08 AM - It Cannot Be Edited


Created By: Jaylena Miller On 01/07/2022 at 09:59 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: VALLEY CHRISTIAN PRESCHOOL
FACILITY NUMBER: 010205821

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2022
Section Cited
CCR
101212(d)(1)(E)

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Reporting Requirements 101212(d)(1)(E)
Upon the occurrence, during the operation of the child care center of any of the events specified in... Events reported shall include the following: (E) Epidemic outbreaks.
This was not met as evidence by:
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Director will submit an unusual incident report (LIC 624) for 12/20/2021 within 7 business days.
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Based on observation, interviews and record review the facility did not report to licensing within 24 hours that the facility had a positive covid on 12/20/2021 which poses a potential risk to the health safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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:Wynn Norona
LICENSING EVALUATOR NAME:Jaylena Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2022


LIC809 (FAS) - (06/04)
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