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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415313
Report Date: 03/15/2021
Date Signed: 03/15/2021 04:02:17 PM

Document Has Been Signed on 03/15/2021 04:02 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:SPRINGS OF LIFE CHRISTIAN PRESCHOOLFACILITY NUMBER:
434415313
ADMINISTRATOR:DENHOLM, JULIEFACILITY TYPE:
850
ADDRESS:3151 UNION AVENUETELEPHONE:
(408) 827-5814
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 45TOTAL ENROLLED CHILDREN: 0CENSUS: 25DATE:
03/15/2021
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Julie DenholmTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico conducted an announced case management tele-inspection via Facetime due to Covid-19 pandemic. The tele-inspection was in response to an unusual incident report that was received by the department on February 8, 2021. LPA met with Executive Director, Julie Denholm. Executive Director was advised that this Facility Evaluation Report Report (LIC 809) will be emailed to her(director@springsoflifechristianpreschool.org). Facility's reply to the email within 24 hours will serve as acknowledgement that the report was received.

Based on available information obtained during the investigation, it was determined that a daycare child went to Room 5 unnoticed by staff and was found by a parent alone in the classroom. The parent shared this to the staff member who was standing outside the door of Room 5. The staff member involved was terminated.

As a result of this inspection, deficiency was cited on the following page.

NOTICE OF SITE VISIT WAS ISSUED. EXECUTIVE DIRECTOR WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.

SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2021
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 03/15/2021 04:02 PM - It Cannot Be Edited


Created By: Marilou Monico On 03/15/2021 at 03:45 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: SPRINGS OF LIFE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 434415313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2021
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision - No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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The staff member who was involved was terminated. Executive Director met with staff members after the incident and discussed best practices including supervision. Supervision of children, headcounting, proper positioning, etc. were discussed during an All Staff Training that was conducted on 02/21/21.
Deficiency corrected.
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This requirement was not met as evidenced by: A daycare child went to Room 5 unnoticed by staff and found by a parent alone in the classroom. This poses a potential risk to the health and safety 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:Anthony Studebaker
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2021


LIC809 (FAS) - (06/04)
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