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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416233
Report Date: 11/22/2022
Date Signed: 11/22/2022 11:47:01 AM

Document Has Been Signed on 11/22/2022 11:47 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CENTENARY ACADEMYFACILITY NUMBER:
434416233
ADMINISTRATOR:ELDA LIUFACILITY TYPE:
850
ADDRESS:383 SPAR AVENUETELEPHONE:
(408) 636-8966
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 35TOTAL ENROLLED CHILDREN: 10CENSUS: 9DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Elda, LiuTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Pietro Hernandez conducted an unannounced, Required 1 Year inspection, met with the Preschool Program Director, Elda Liu, and explained the nature of today's inspection. The following ratios in the rooms currently used during time of inspection:
Front playroom: 1 Teacher and the Director and 9 preschoolers.

The facility was in compliance with teacher/ child ratios, children were not left unattended and were constantly under the direct visual supervision of a staff person. LPA noted the staff and children were interacting in various activities. Normal Business hours Monday - Friday 8:00 AM to 6:00 PM.

LPA completed a physical plant inspection touring the building inside and out. No bodies of water were found. Director stated that there are no weapons stored in the facility. Disinfectants, cleaning solutions, poisons, and other items that are dangerous to children were locked up and inaccessible. Furniture and equipment was in good condition, free of sharp, loose, or pointed parts.

Facility has age appropriate furniture and equipment. All storage containers for solid waste had tight fitting covers and were in good repair. Facility was free of flies, other insects, and rodents. Facility has adequate indoor activity space for children that is physically separate from space used by the preschool child care center. Water bottles, dishes, and containers of food brought by the child's authorized representative are labeled with the child's name and current date. Facility has at least one functioning carbon monoxide detector, several fire extinguishers (3A40BC) and fire pull stations that meets statutory requirements. Facility has adequate outdoor activity space and play equipment that is maintained in a safe condition and is free of hazards.
Continued on Page #2. Report dated 11/22/2022
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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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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: CENTENARY ACADEMY
FACILITY NUMBER: 434416233
VISIT DATE: 11/22/2022
NARRATIVE
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The outdoor activity area is surrounded by appropriate fencing. The play structure and equipment outside were age appropriate in good condition. Areas around play structure were cushioned with resilient materials. Shaded rest areas are provided by canopy and trees. LPA did not observe any bodies of water.

NOT ALL All Staff were fingerprinted and associated to the facility. LPA reminded Director of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day with a maximum of $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day with a maximum of $3000.00 per person. LPA also reviewed with Director the violations that would result in an immediate assessment of civil penalty in the amount of $500. Director is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.

There was at least one Teacher with current certification in Pediatric CPR and First Aid present at the facility during inspection. Children's Roster was reviewed, and will be e-mailed to the LPA.

LPA Hernandez reviewed the files of 1 Staff and 8 children. All or the required documentation was available in the Children's file. One staff file was missing and not associated to the facility

This facility does not provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A 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

Continued on Page #3 of Report dated 11/22/2022
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
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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: CENTENARY ACADEMY
FACILITY NUMBER: 434416233
VISIT DATE: 11/22/2022
NARRATIVE
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LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed: www.mandatedreporterca.com.

Type A citations today, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with the Licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Elda Liu, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2022 11:47 AM - It Cannot Be Edited


Created By: Pietro Hernandez On 11/22/2022 at 11:03 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: CENTENARY ACADEMY
FACILITY NUMBER: 434416233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. Staff1, S1, was npt associated tot he facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2022
Plan of Correction
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By the POC date the Licensee will get the staff associated prior ro having the staff work or volunteer for the facity and provide a plan of correction in writing that addresses how the licensee will avoid this issue going forward and be compliaent.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2022 11:47 AM - It Cannot Be Edited


Created By: Pietro Hernandez On 11/22/2022 at 11:03 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: CENTENARY ACADEMY
FACILITY NUMBER: 434416233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observatio], the licensee did not comply with the section cited above Staff 1 did not have a file with required documentation for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2022
Plan of Correction
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By the POC date the Licensee will provide a complete file for S1 containing all the required documentationa and a written plan of correction explaining how she will avoid this issue going forward and be compliant.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
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