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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434412171
Report Date: 07/10/2024
Date Signed: 07/10/2024 02:13:13 PM

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
06/12/2024 and conducted by Evaluator Marilou Monico
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240612132752
FACILITY NAME:KIDDIE ACADEMY OF CUPERTINOFACILITY NUMBER:
434412171
ADMINISTRATOR:JACALNE, MARIA SOCORROFACILITY TYPE:
850
ADDRESS:19875 STEVENS CREEK BLVD.TELEPHONE:
(408) 517-0454
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:119CENSUS: 91DATE:
07/10/2024
UNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Maria Socorro JacalneTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Facility failed to provide injury report to parent
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marilou Monico met with Site Director, Maria Socorro Jacalne, for a follow-up complaint inspection. LPA interviewed staff, reviewed staff files, and obtained copy of documents.

Based on interviews, it was determined that a parent requested a copy of injury report, however, the facility failed to meet the request. The preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED.

As a result, Type B deficiency was cited on the following page.

A Notice of Site Visit was given and must remain posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
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-20240612132752
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: 07/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2024
Section Cited
CCR
101212(f)
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Reporting Requirements - The items specified in (d)(1)(A) through (H) shall also be reported to the child's authorized representative.
This requirement was not met as evidenced by:
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Site Director stated that an All Staff Meeting was conducted on 06/24/24 and reporting requirements was discussed. Site Director stated that she will submit a written plan to ensure that parents are provided a copy of incident/injury report within the required time frame.
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The facility failed to provide an injury report to parent. This poses a potential risk to the health, safety, and personal rights to persons 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: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC9099 (FAS) - (06/04)
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