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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274403572
Report Date: 10/21/2025
Date Signed: 10/21/2025 11:16:25 AM

Document Has Been Signed on 10/21/2025 11:16 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:OUR SAVIOR'S EARLY CHILDHOOD CENTERFACILITY NUMBER:
274403572
ADMINISTRATOR/
DIRECTOR:		SUSAN KLEMSZFACILITY TYPE:
850
ADDRESS:1230 LUTHER WAYTELEPHONE:
(831) 422-4614
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 10DATE:
10/21/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Susan KlemszTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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On October 21, 2025, Licensing Program Analyst (LPA) Darnella Barnes conducted an unannounced annual inspection at the facility located on the campus of Lutheran Church of Our Savior. The facility operated Monday through Friday, from 7:30 a.m. to 5:30 p.m. LPA explained the purpose of the visit to Director Susan Klemsz, who granted access and received the Entrance Checklist (LIC 125). Present during the inspection were the Director Susan Klemsz, Pastor Scott Klemsz, Mike Coleman, one teacher, and ten children.

All required postings were clearly visible. The most recent fire drill was conducted on 10/21/25. LPA reminded the Director that fire drills must be conducted at least every six months and properly documented. A fully charged 3A-40-BC fire extinguisher, last serviced on 5/5/25, was observed. Each classroom contained a carbon monoxide detector and had a built-in fire detection system. A working telephone was available. The Director confirmed that no firearms were kept on the premises.

Director 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

Meals provided by the facility included a morning and afternoon snack. Parents were responsible for providing lunch and a water bottle for their child. Additional water was available through a filtered water system, and extra food was kept on hand if needed.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2025
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: OUR SAVIOR'S EARLY CHILDHOOD CENTER
FACILITY NUMBER: 274403572
VISIT DATE: 10/21/2025
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The indoor space was clean, safe, and well-maintained. Flooring was in good condition, with no tripping or slipping hazards. Toy bins had smooth edges, ventilation, and finger-safe lids. Each child had a labeled storage space. Sleeping mats were at least one inch thick and easily cleanable. Each child had their own sheet and blanket. Mats were cleaned daily.

Bathroom facilities met the required ratio of one toilet and one sink per 15 children. All toileting areas, including sinks, walls, and floors, were routinely cleaned and disinfected.

Cleaning products and chemicals were stored in locked cabinets, away from food and out of children's reach. Floors were mopped and carpets vacuumed daily. Trash was placed in containers with lids. The indoor temperature was recorded at 68°F.

LPA reviewed five children’s files. All files were complete and contained the Admission Agreement, Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Physician's Report (LIC 701), immunization records, TB test results, Personal Rights (LIC 613A), Notification of Parent's Rights (LIC 995A), and Pre-admission Health History.

The facility roster and sign-in/out sheets were reviewed. All entries used full legal signatures and included accurate times.

One staff file was reviewed. It included documentation of Pediatric First Aid/CPR certification, Mandated Reporter Training, job application, health screening, child abuse reporting acknowledgment, employee rights form, and educational qualifications. LPA reminded the Director that Mandated Reporter Training must be renewed every two years, and at least one staff member must always have current CPR/First Aid certification. LPA also advised that aides and assistants must remain under direct supervision of a qualified teacher, except during naptime or when children are using the restroom.

During the outdoor inspection, LPA observed that walkways, ramps, and stairs were free from hazards. The play area had proper shade and was arranged to reduce risk of injury. The outdoor space was fully enclosed with a fence at least five feet high. The yard was free from debris, accessible hazards, and bodies of water.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
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: OUR SAVIOR'S EARLY CHILDHOOD CENTER
FACILITY NUMBER: 274403572
VISIT DATE: 10/21/2025
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First aid supplies were observed in an accessible location for staff and out of children's reach. The kit included a first aid manual, bandages, scissors, adhesive tape, thermometer, tweezers, and antiseptic solution.

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/.



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 childcare center licenses issued after July 1, 2022, the Site Supervisor 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 in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Director was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California..

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 inspection the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.



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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
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: OUR SAVIOR'S EARLY CHILDHOOD CENTER
FACILITY NUMBER: 274403572
VISIT DATE: 10/21/2025
NARRATIVE
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No deficiency issued during today's inspection.

A notice of site visit was given and must remain posted for 30 days. Appeals rights provided.

Exit interview conducted and report was reviewed with Director, Susan Klemsz

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC809 (FAS) - (06/04)
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