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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410829
Report Date: 06/23/2023
Date Signed: 06/23/2023 04:19:21 PM

Document Has Been Signed on 06/23/2023 04:19 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SAN JOSE CHRISTIAN PRESCHOOLFACILITY NUMBER:
434410829
ADMINISTRATOR:ASHLEY KOEPPLINFACILITY TYPE:
850
ADDRESS:1300 SHEFFIELD AVENUETELEPHONE:
(408) 371-7741
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 84TOTAL ENROLLED CHILDREN: 52CENSUS: 34DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Monique NicoleauTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ashley Lopez and Cortney Nelson arrived at facility to conducted an unannounced Annual Required Inspection. LPAs met with Director, Monique Nicoleau, who guided LPAs on a tour of the facility indoors and outdoors.

The preschool consists of 4 of classrooms. The preschool operates from 8:00am-5:00pm Monday through Friday. This facility has a capacity of 84 children, with 34 children present today. LPAs observed that teacher-child ratio was met during the inspection. All teachers present have a criminal record clearance. All children were observed to be always under visual supervision of a teacher.

LPAs inspected all 4 preschool classrooms during todays visit. Room #1 is Fireflies had 7 preschoolers. Room #2 is the Dragon Flies, there were 8 children present. Room #10 is the Butterflies and there were 9 children present. And Room #11 was the Grasshoppers and there were 10 children present. The classrooms were inspected to be clean, safe, sanitary and in good repair. The floors have a surface that is safe and clean. All toilets and hand washing facilities are in safe and sanitary operating conditions.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Ashley Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SAN JOSE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 434410829
VISIT DATE: 06/23/2023
NARRATIVE
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Preschoolers bring their lunch from home and they are kept in personal lunch bags. Facility will provide an emergency lunch if a child does not bring a lunch. All sink and kitchen and storage areas are clean, free of litter, rubbish, and rodents/vermin. Children bring their water bottles from home and water is provided by delivery water bottle service. All storage containers for solid waste, including moveable bins, have tight fitting covers on and are in good repair. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are stored in an area inaccessible to children. The director states there are no poisons or weapons in facility. Facility has functioning smoke detectors and carbon monoxide detectors that meets statutory requirements.

LPAs observed an outdoor play structure that had cracked from being in the sun. The director had a maintenance worker remove the structure while LPAs were outside conducting the inspection. The other outdoor play equipment was observed to be in good condition, free of sharp, loose or pointed parts. Outdoor activity space surface is maintained in a safe condition as is free of hazards. LPAs advised the director to have more resilient material put into the play ground area. The director stated that once a year they have a maintenance service refill the resilient material in the playground. LPAs did observe a blow up jumper that is used with water, the director states they have it in the playground on Fridays for the preschool children. LPAs advised to have the teachers supervise the children at all times and follow the body of water regulations.

Sign in and out sheets were reviewed by LPAs to ensure that children who are present were signed in. LPAs observed that the parents/legal guardians are having the children sign themselves out on the electronic sign out sheets. LPA advised the director to inform parents/legal guardian that they are the only ones who can sign the children in and out of the school. 5 children’s records were reviewed for completeness. In review of children’s records, the files are missing the LIC 613A. LPAs advised director to have parents complete the forms. 5 staff files were reviewed. Of the 5 files one staff member did not have current immunizations, and one did not have current Mandated Reporter Training for Child Care Workers. All staff have current CPR and First Aid certifications on file. Director 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.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Ashley Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SAN JOSE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 434410829
VISIT DATE: 06/23/2023
NARRATIVE
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SB792 (Immunization Requirements for Staff and Employees) was discussed with the director. AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers

Incidental Medical Services (IMS) policy was discussed. This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA advised director, Monique Nicoleau, to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.goEv.

There are deficiencies being cited during today’s inspection.
A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with director, Monique Nicoleau.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Ashley Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/23/2023 04:19 PM - It Cannot Be Edited


Created By: Ashley Lopez On 06/23/2023 at 03:24 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: SAN JOSE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 434410829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 facility did not comply with the section cited above in 1 out of 5 staff file reviews which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Director states she will submit proof of Immunizations for Staff #1 or plans of when staff will obtain immunizations to licensing by 6/30/23.
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 in 1 out of 5 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Director states that she will submit proof of Mandated Reporter Training for Staff #4 to licensing by 7/7/23.
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:Ashley Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/23/2023 04:19 PM - It Cannot Be Edited


Created By: Ashley Lopez On 06/23/2023 at 03:24 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: SAN JOSE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 434410829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101223(b)(1)
Personal Rights
(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]).

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 in 8 out of 8 childrens files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Director Monique Nicoleau states she will send proof of completed LIC 613A for the 8 children to licensing by 6/30/23. LPA advised Director to review all of the childrens files to make sure the LIC 613A is in the files.
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the parents of the preschool children are having the children sign themselves in and out of school which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Director Monique Nicoleau stated she will contact parents through email about the sign in/out sheets. The director will implement a paper sign in/out sheet as well to ensure parents will make sure to sign in the children. Director will submit proof of paper sign in sheet and email to licensing by 6/30/23.
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:Ashley Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/23/2023 04:19 PM - It Cannot Be Edited


Created By: Ashley Lopez On 06/23/2023 at 03:39 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: SAN JOSE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 434410829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
(g) All personnel, including the licensee, administrator and volunteers, shall be in good health and shall be physically and mentally capable of performing assigned tasks.

(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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Based on record review, the facility did not comply with the section cited above in 3 out of 5 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Director states she will send proof of completed LIC 503 forms to licensing by 7/7/23. LPAs advised director to review all staff files to make sure files have the completed forms.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ashley Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
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