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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416995
Report Date: 11/02/2022
Date Signed: 11/02/2022 01:54:31 PM

Document Has Been Signed on 11/02/2022 01:54 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:VIDYARAMBH CUPERTINOFACILITY NUMBER:
434416995
ADMINISTRATOR:SUJATHA NAMBOODIRIFACILITY TYPE:
850
ADDRESS:10041 NORTH BLANEY AVENUETELEPHONE:
(408) 444-5019
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 47TOTAL ENROLLED CHILDREN: 17CENSUS: 11DATE:
11/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sujatha NamboodiriTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Marilou Monico met with Site Director, Sujatha Namboodiri, for a Case Management Inspection in response to an unusual incident that was self-reported by the facility to Licensing on October 20, 2022. The incident occurred on October 19, 2022 involving a daycare child, C1. Only the first page of the Unusual Incident Report (LIC 624) was submitted to Licensing. LPA obtained copy of the second page of LIC 624.

During today's inspection, LPA interviewed staff (S1 & S2) and children (C1 & C2). LPA toured the playground. Based on interviews, LPA learned that on October 19, 2022, there were two staff members, S1 & S2, in the playground with around 14 children. The children were playing tug and they were running. C1 tripped and fell on the hilly grass area of the playground and rolled towards the cemented walkway area. The incident was observed by S1, S2 & C2. C1 got up and was holding her right arm. A staff member contacted 911 and the parents were notified. The parents brought C1 to the hospital. The x-ray showed fracture on the right arm and C1 received a cast.

Based on information gathered from interviews and documents obtained, there were no deficiencies cited.


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: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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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