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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434412171
Report Date: 08/04/2022
Date Signed: 08/04/2022 10:17:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2022 and conducted by Evaluator Pietro Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20220509094131
FACILITY NAME:KIDDIE ACADEMY OF CUPERTINOFACILITY NUMBER:
434412171
ADMINISTRATOR:SANA, KATHY MAEFACILITY TYPE:
850
ADDRESS:19875 STEVENS CREEK BLVD.TELEPHONE:
(408) 517-0454
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:119CENSUS: 100DATE:
08/04/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angela XiongTIME COMPLETED:
10:30 PM
ALLEGATION(S):
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1) Staff caused an injury to a day-care child while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pete Hernandez conducted an unannounced Subsequent Complaint Investigation at the Facility. LPA met with Angela Xiong and the finding for the above allegation was also delivered to the Facility during the visit.

Complainant alleges that Staff caused an injury to a day-care child while in care.
During the course of the investigation, LPA inspected the Preschool, reviewed records, and conducted interviews.

Continued on page 2 LIC9099C dated 8/4/2022.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 07-CC-20220509094131
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KIDDIE ACADEMY OF CUPERTINO
FACILITY NUMBER: 434412171
VISIT DATE: 08/04/2022
NARRATIVE
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On 5/2/2022, A Teacher help on to a Child's hand to run inside for lunch and the child refused. The child pulled back to get out of the Teacher's grasp. The Child cried and stated their left arm hurt. The Child was taken in for medical treatment. The Child's Father had informed the Director of the Child's diagnosis and requested staff training on the appropriate handling of children to prevent injuries. On 5/6/2022 the Child refused to nap and was disruptive. A Teacher had repeately asked the child to stop and gently grabbed the Child's forearm and lead the Child away from the other napping children. The child, again, pulled away and to run away and began crying. The child claimed their arm hurt, and was taken back for medical treatment at an urgent care a second time. The Treating Physician stated that this child has a high susceptibility of getting injured due to their condition.

On 5/9/2022 the Director held a virtual staff meeting to address these two incidents and the proper handling of children. Substitutes were not included in the meeting.

Although the Child was injured; The department did not find that the Staff's actions constitute child abuse.
Based on the interviews and information obtained throughout the investigation, the preponderance of evidence standard has been met. Therefore, the allegation: is
SUBSTANTIATED.

LPA discussed the requirements of AB 633 with the Licensee/Director (provide name) and provided the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and the Licensee/Director understands the requirements. Upon receipt, Licensee/Director Angela Xiong shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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, see LIC9099D, An exit interview was conducted, and Plan of Correction was reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with the Licensee, Angela Xiong, 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: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 07-CC-20220509094131
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KIDDIE ACADEMY OF CUPERTINO
FACILITY NUMBER: 434412171
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2022
Section Cited
CCR
101223(a)(2)
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101223(a)(2) Personal Rights: (a)The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.This requirement is not met as evidenced by:
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By the end of the POC day, Licensee will complete and will submit a written plan to Community Care Licensing outlining how the facility will ensure that all staff are trained in proper handling of children and ensure that training of future staff are trained to prevent further injuries from inproper handling of Children. Plan of Correction was recieved on the 8/4/2022 of findings delivery.
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The Facility Staff were not trained in proper handling of children requested immediatly following the first incident by a parent. Training and awareness of staff did not occur until after the second incident. This presents an immediate risk to health and safety of the 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.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
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