Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703409
Report Date: 01/04/2018
Date Signed 01/04/2018 11:12:50 AM

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:YOUNG LIFE CHRISTIAN PRE-SCHOOL CENTERFACILITY NUMBER:
430703409
ADMINISTRATOR:DIANE CHAMBERSFACILITY TYPE:
850
ADDRESS:687 ARASTRADERO RDTELEPHONE:
(650) 494-7885
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:31CENSUS: 17DATE:
01/04/2018
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Diane ChambersTIME COMPLETED:
11:15 AM
NARRATIVE
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Unannounced random visit made by Analyst Mahvash Behbood. Met Staff Maria Garcia, present also were 9 children and one additional staff. Site Director Diane arrived during visit Operation hours is M-F from 7:30 to 6:30. Indoor and outdoor of the facility was toured. .
Menu, licenses, Personal Rights, Car Seat Poster & Parent's Rights are all posted.
LPA reviewed samples of children's file and sign in and out sheets during today's visit. Each child's file reviewed contains the Information and Emergency Information form (LIC 700) and a copy of the admission agreement. LPA observed that all children were properly signed in and out (legal signature & time of day) by a parent or authorized representative. A few staff have current CPR and First Aid certifications.
Teacher/children ratio was met during the visit.
A sampling of children's files were reviewed & are complete.
Furniture & equipment appear in good condition. Floors appear clean. Children's bathrooms are in operating condition. medications stored inaccessible to children. Ms.Chambers understands when medication is accepted to administer by center all medication must be in their original container accompanied by parent's and physician's permission/direction in addition to the mediation log
Playground has climbing structures, , sand boxes, etc. Wood chips and rubber chips are used for cushioning material.
Drinking water inside the classrooms are provided via pitcher and cups and in the playground are provided via water fountains.
Center provides snacks. The menu is posted & has the required food groups. Kitchen appears clean. All food is covered & there is a trash can with a tight-fitting cover. children were visually supervised.
Incidental Medical Services were discussed with the licensee. This facility provides Incidental Medical Services (IMS). LPA reviewed storage of medication and equipment /supplies, and reviewed children’s, personnel and administrative records.
Please see next page for citation under Title 22.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2018
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: YOUNG LIFE CHRISTIAN PRE-SCHOOL CENTER
FACILITY NUMBER: 430703409
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2018
Section Cited
CCR
101226(e)(4)(A
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Health Related Services - Prescription medications shall be administered in accordance with the product label directions on the nonprescription medication container(s). One child's inhaler medication expired in 10/2017. Another's child inhaler medication was not in its original container.
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The expired medication will be delivered to parent no later than 01/04/2018..
Director will submit to licensing a plan which would ensure medication will be checked and the facility will not store expired medication. The plan must be received no later than 01/29/18.
Type B
01/29/2018
Section Cited
CCR
1596.7995
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Health and Safety - Employees or Volunteers must have appropriate records for immunizations for measles, whooping cogh and if they choose flue shot.
Non of the staff have proof of immunization on file for review.
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Facility to provide records of immunization against measles, whooping cough and if they choose flue shot/or decline in writing 9flue shot only) for all staff no later than 01/29/2018
Type B
01/29/2018
Section Cited
CCR
101173(c)
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Plan of operation - Any proposed changes in the plan of operation that affect services to children shall be subject to departmental approval prior to implementation and shall be reported as specified in Section 101212.
IMS is being provided without IMS Plan of operation submitted to department.
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Plan of operation for IMS must be submitted no later than 01/29/2018.
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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: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2018
LIC809 (FAS) - (06/04)
Page: 2 of 2