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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412172
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:46:09 PM

Document Has Been Signed on 05/15/2023 02:46 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: 18CENSUS: 15DATE:
05/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Angela XiongTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico met with Site Director, Angela Xiong, and conducted a Case Management Inspection regarding an unusual incident that was self-reported by the facility to Licensing on May 2, 2023. LPA toured the facility and interviewed staff.

Based on interviews and available evidence, LPA learned that on May 2, 2023, a staff (S-1) was preparing to remove a child (C-1) from the high chair after meal time. S-1 pulled out the tray attached to the high chair and turned away to place the tray in the sink. C-1 leaned forward in the high chair and fell on the floor. C-1 had a bloody nose. Site Director contacted C-1's dad immediately. C-1 was brought to the doctor. Site Director called the mom to check on C-1 and the mom indicated that C-1 was okay and that the doctor told her to monitor C-1 at home. Site Director stated that C-1 returned to the center the next day after the incident. Site Director stated that one on one training with all staff in the infant program was conducted on May 3, 2023 and May 4, 2023 regarding high chair safety, standard infant room operating procedures, supervision, feeding, and communication. Site Director stated that the high chairs were replaced with floor high chairs.

LPA observed three floor high chairs in the infant room. LPA obtained copy of training agenda and attendance sheet during today's visit.

Exit interview was conducted and report was reviewed with Site Director, Angela Xiong.

As a result of this inspection, deficiency was cited on the following page:

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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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Document Has Been Signed on 05/15/2023 02:46 PM - It Cannot Be Edited


Created By: Marilou Monico On 05/15/2023 at 01:18 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: 05/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2023
Section Cited
CCR
101223(a)(2)

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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 was not met as evidenced by:
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Site Director conducted one on one training with all staff in the infant program regarding high chair safety, standard infant room operating procedures, supervision, feeding, and communication. The high chairs were replaced with floor high chairs.

Deficiency corrected.
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Based on interviews and available evidence, a child (C-1) fell from the high chair when a staff (S-1) removed the tray attached to the high chair and turned away to place the tray in the sink. This poses an immediate risk to the health, safety, and personal rights of children in care.
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Upon receipt, licensee 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.

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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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


LIC809 (FAS) - (06/04)
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