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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434415329
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:35:33 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2024 and conducted by Evaluator Jialing Zhu
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20240827091109
FACILITY NAME:STANFORD MADERA GROVE CHILDREN'S CENTERFACILITY NUMBER:
434415329
ADMINISTRATOR:ZARCONE, SALLYFACILITY TYPE:
850
ADDRESS:751 OLMSTED ROADTELEPHONE:
(650) 721-6632
CITY:STANFORDSTATE: CAZIP CODE:
94305
CAPACITY:144CENSUS: 99DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kimberly KostepenTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Personal Rights: Staff member hit a day care child.
INVESTIGATION FINDINGS:
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 On 09/26/2024 at 12:00pm, Licensing Program Analyst (LPA) Jialing “Julianne” Zhu conducted an unannounced complaint site inspection. LPA met with director, Kimberly Kostepen. LPA advised director the purpose of this visit is to deliver findings for the complaint investigation. Present during the inspection was 21 fingerprint-cleared staff and 99 children.
During today’s inspection, LPA requested and obtained access to facility’s incident reports. Throughout the course of this complaint investigation, LPA obtained copies of the facility roster and personnel record, reviewed staff and children’s files, and conducted interviews with the Reporting Party (RP), director, staff members, and parent. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation stated above did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Report was reviewed, exit interview was conducted, and Appeal Rights were provided to director, Kimberly Kostepen. Notice of Site Visit was given and must remain posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2024 and conducted by Evaluator Jialing Zhu
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20240827091109

FACILITY NAME:STANFORD MADERA GROVE CHILDREN'S CENTERFACILITY NUMBER:
434415329
ADMINISTRATOR:ZARCONE, SALLYFACILITY TYPE:
850
ADDRESS:751 OLMSTED ROADTELEPHONE:
(650) 721-6632
CITY:STANFORDSTATE: CAZIP CODE:
94305
CAPACITY:144CENSUS: 99DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kimberly KostepenTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Reporting Requirements: Facility did not notify CCLD of incident.
INVESTIGATION FINDINGS:
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5
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13
 On 09/26/2024 at 12:00pm, Licensing Program Analyst (LPA) Jialing “Julianne” Zhu conducted an UNANNOUNCED COMPLAINT SITE INSPECTION. LPAs met with director, Kimberly Kostepen. LPA advised director the purpose of this visit is to deliver findings for the complaint investigation. Present during the inspection was 21 fingerprint-cleared staff and 99 children.
During today’s inspection, LPA requested and obtained access to facility’s incident reports. Throughout the course of this complaint investigation, LPA obtained copies of the facility roster and personnel record, reviewed staff and children’s files, and conducted interviews with the Reporting Party (RP), director, staff members, and parent. Based on LPA’s observations and the evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1, Article 06, 101212(d), is being cited on the attached LIC 9099D.
Report was reviewed, exit interview was conducted, and Appeal Rights were provided with director, Kimberly Kostepen. Notice of Site Visit was given and must remain posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 52-CC-20240827091109
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: STANFORD MADERA GROVE CHILDREN'S CENTER
FACILITY NUMBER: 434415329
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2024
Section Cited
CCR
101212(d)
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Reporting Requirements 101212(d) ... during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
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Reporting requirements for Unusual Incidents and Injuries Reports (UIRs) have been discussed between director and LPA via email. Director has demonstrated understanding of reporting requirements as she submitted UIRs following the discussion.
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Based on observation and interview, the licensee did not comply with the section cited above as there is no record of the incident reported to Licensing, which posed a potential health, safety or personal rights risk to persons in care.
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LPA provided director with a copy of the regulations for Reporting Requirements to review and for future guidance.
CCR
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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: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3