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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412172
Report Date: 08/24/2022
Date Signed: 08/24/2022 08:45:51 PM

Document Has Been Signed on 08/24/2022 08:45 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
SAN JOSE-DAY CARE, 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:
4085170454
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 8DATE:
08/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Angela XiongTIME COMPLETED:
12:50 PM
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On 8/24/2022 Licensing Program Analyst LPA Stephanie Collins conducted an unannounced Case Management- Other visit based on the a self reported unusual Incident report (UIR) dated August 18th 2022. LPA met with Licensee Director Angela Xiong
explained the reason for the inspection. Present during today's inspection were 8 infants and 2 staff.

Based on the information obtained though witness statements, interviews, and review of the preschools security video the alleged incident may or may not have happened. Consequently, the preponderance of evidence collected does not support the veracity of the alleged incident of record, Therefore, the above incident is found be unsubstantiated .





A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.







SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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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