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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412172
Report Date: 06/09/2021
Date Signed: 06/09/2021 05:06:22 PM

Document Has Been Signed on 06/09/2021 05:06 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:KIDDIE ACADEMY OF CUPERTINOFACILITY NUMBER:
434412172
ADMINISTRATOR:XIONG, ANGELAFACILITY TYPE:
830
ADDRESS:19875 STEVENS CREEK BLVD.TELEPHONE:
(408) 517-0454
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 24TOTAL ENROLLED CHILDREN: 0CENSUS: 14DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kathy Mae SanaTIME COMPLETED:
03:30 PM
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#2 Licensing Program Analysts (LPAs) Marilou Monico and James Santos conducted an unannounced Annual inspection. LPAs met with Interim Director, Kathy Mae Sana and informed her the purpose of the visit. Facility's License, Notification of Parents’ Right Poster, Child Car Seat Law, waivers, Personal Rights (LIC 613A), Emergency Disaster Plan, and Earthquake Preparedness Checklist were observed to be posted. The center's operating hours are Monday through Friday 07:00 AM to 06:30 PM. Age serve is zero to 24 months.

The Infant Program is operating in Rooms 1 and 2. The children in the Infant Program have their own playground separated from the preschool/school age yard.

LPAs toured the facility both indoor and outdoor. LPAs observed that the facility was operating in compliance with teacher to children ratio requirement. Children were under the supervision of the teachers. The classrooms and storage areas were inspected. There were no bodies of water observed. Interim Director stated that facility do not have weapons on the premises. Furniture and equipment were observed to be age appropriate and in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, poisons, and other items that are dangerous to children were stored inaccessible to children. Floors were clean.

Outdoor activity space is enclosed by fencing and is observed to be free of hazards. LPAs observed play equipment were in good condition. Drinking water was readily available to children indoor and outdoor. Activities schedule and Menu were posted. Facility provides lunch and snacks (morning and afternoon). Lunch and snacks are prepared at the facility. . LPAs observed that food storage areas were clean and free of litter. LPAs observed that each infant has current feeding, diaper, and nap log. The center has documentation that sleeping infants were checked every 15 minutes. Diapers are being disposed appropriately. Each infant has personal items individually stored and labeled.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIDDIE ACADEMY OF CUPERTINO
FACILITY NUMBER: 434412172
VISIT DATE: 06/09/2021
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Foods and beverages were kept protected against contamination and spoilage. Trash cans for solid waste had tight-fitting covers on, and were in good repair. First Aid Kit was inspected. Fire extinguisher, smoke and carbon monoxide detectors were observed.

This facility is providing Incidental Medical Services – IMS Plan. LPAs reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information, see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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.

LPAs reviewed sign in and out record, and procedure. A sampling of children and staff files was taken for review during today's inspection. Children records reviewed include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, Medical Assessment and Immunization.

Staff records reviewed include Criminal Record and Child Abuse Index Clearance, Health Screening Report with TB Clearance, Immunization (Measles, Pertussis, and Flu) record and required Training. LPA reminded Interim Director that the online AB1207 Mandated Reported Training needs to be renewed every two years. Teachers and Interim Director who are present during the physical plant inspection have the required qualifying education credits and experience. There was at least one person with current certification in Pediatric CPR and First Aid present at the facility.

LPAs reminded Interim 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 up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIDDIE ACADEMY OF CUPERTINO
FACILITY NUMBER: 434412172
VISIT DATE: 06/09/2021
NARRATIVE
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LPAs also reviewed with Interim Director the violations that would result in an immediate assessment of civil penalty in the amount of $500. Site Director is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.

In the areas that were evaluated, two regulatory violations were observed at the time of the visit; therefore a citations were issued. Exit interview was conducted, where this report, the citations, plan of corrections, and appeal rights were reviewed with Interim Director.

A copy of this report was provided to the facility at the conclusion of the inspection.

NOTICE OF SITE VISIT WAS ISSUED. INTERIM DIRECTOR WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/09/2021 05:06 PM - It Cannot Be Edited


Created By: Marilou Monico On 06/09/2021 at 02:49 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: KIDDIE ACADEMY OF CUPERTINO
FACILITY NUMBER: 434412172

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2021
Section Cited
CCR
101493.3(a)

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Modifications to Infant Needs and Services Plan - The written infant needs and services plan shall be updated at least quarterly, or as often as necessary to assure its accuracy. This requirements was not met as evidenced by: LPAs observed that the Infant Needs and Services Plan of C-1, C-2, and C-3 were not updated quarterly. This poses a potential risk to the health and safety of children in care.
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Interim Director states that she will submit an updated Infant Needs and Services Plan for C-1, C-2, and C-3 to Licensing by 06/16/21.
Type B
07/09/2021
Section Cited
HSC
1596.8662(b)(1)

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training
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Interim Director states that Mandated Reporting Training proof of completion for Staff #1 will be submitted to Licensing by 07/09/21.
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This requirement was not met as evidenced by: Staff #1's Mandated Reporter Training is expired. This poses a potential risk to the health and safety of 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.
SUPERVISOR'S NAME:Anthony Studebaker
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021


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