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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416233
Report Date: 05/08/2024
Date Signed: 05/08/2024 02:24:15 PM

Document Has Been Signed on 05/08/2024 02:24 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:CENTENARY ACADEMYFACILITY NUMBER:
434416233
ADMINISTRATOR/
DIRECTOR:		ELDA LIUFACILITY TYPE:
850
ADDRESS:383 SPAR AVENUETELEPHONE:
(408) 636-8966
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 35TOTAL ENROLLED CHILDREN: 16CENSUS: 16DATE:
05/08/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Elda LiuTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Plan of Correction (POC) inspection. LPA met with Licensee/Director Elda Liu and explained the reason for the inspection. The purpose of this inspection is the center was cited on 04/17/2024 for ratio, supervision, lead testing and paperwork. Present during today's inspection were 16 children and three staff.

During today's inspection, LPA conducted observation. LPA also discussed with Licensee the forms that need to be maintained in staff files and about personnel requirements. LPA informed Licensee that volunteers cannot be included in staffing plan. LPA reviewed staff files.

LPA observed that children were in Room 2. Staff walked out of the room. LPA also observed at 12:25PM that a child went to the restroom. There was no staff at the door of the restroom where they can visually supervise the child. Director moved where she can see the children in Room 2 and went to stand at the door of the restroom. Licensee understands that children need to be supervised, including visually , at all times. LPA also understands that if there is only one fully qualified teacher and an aide with no units that they can only care for 15 children at one time. LPA observed that one of the teachers stepped out of the room leaving one fully qualified teacher and an aide with no units with 16 children.

LPA also discussed with Licensee about the Technical Support Program. LPA also discussed the requirements if the center receives a Type A citation and the posting requirements.

LPA received LIC 9275, LIC 9276, LIC 999, and lead test results via email during today's inspection.

Licensee will submit the following:
- S-1's Health Screening, TB test, immunization records for MMR, Tdap, and influenza
- S-2's immunization record for MMR that has name on it
- written plan on how she will ensure center is within ratio and will supervise children at all times

As a result of this inspection, a Type B citations were issued. A civil penalty of $250 was assessed for repeat violation. Exit interview conducted and report was reviewed with Licensee. A notice of site visit has been issued.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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 05/08/2024 02:24 PM - It Cannot Be Edited


Created By: Samantha Yip On 05/08/2024 at 12:35 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: CENTENARY ACADEMY
FACILITY NUMBER: 434416233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
101216.3(b)

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Teacher-Child Ratio. The licensee may use teacher aides in a teacher-child ratio of one teacher and one aide for every 15 children in attendance.
This requirement is not met as evidenced by:
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By POC 05/17/2024, Licensee will submit written plan on she will ensure that she is within ratio at all times.
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Based on observation, LPA observed that staff stepped of the room leaving only one fully qualified teacher and an aide without units with 16 children. This poses a potential health and safety risk to children in care.
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Type B
05/17/2024
Section Cited
CCR101229(a)(1)

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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation.
This requirement is not met as evidenced by:
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By POC 05/17/2024, Licensee will submit plan on how she will ensure that children are supervised at all time.
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Based on observation, LPA observed that a staff stepped out of Room 2 where there were children. There was no other staff in the room at the time. LPA also observed that a child was in the restroom. This poses a potential health and safety risk to children in care.
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Director moved to the door, so she can visually supervise children during the inspection.
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:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024


LIC809 (FAS) - (06/04)
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