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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013422426
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:46:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/03/2022 and conducted by Evaluator Simerjit Kaur
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20220803113425
FACILITY NAME:KIDDIE ACADEMYFACILITY NUMBER:
013422426
ADMINISTRATOR:BRUCE, SHANNONFACILITY TYPE:
840
ADDRESS:1400 N VASCO RDTELEPHONE:
(925) 292-1948
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:14CENSUS: 20DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Ebonee LuceroTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Record Keeping- Staff files are incomplete
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Simerjit Kaur and Julia Placencia arrived at the facility unannounced to conduct an investigation into the above allegation. LPAs met with Assistant Director Ebonee Lucero. Present during today's inpection were 20 school aged children and 2 staff members.
During the course of the investigation, LPAs conducted interviews and record review. Based on record review, the facilty have incomplete staff files in the school age component. The allegation that the staff files are incomplete has been SUBSTANTIATED. Based on evidence gathered, the standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
See attached LIC 9099D. A copy of this report, and Appeal Rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Simerjit KaurTELEPHONE: (510) 622-2632
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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 2
Control Number 52-CC-20220803113425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: KIDDIE ACADEMY
FACILITY NUMBER: 013422426
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2022
Section Cited
CCR
1596.7995(a)(1)
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(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
This requirement is not met as evidenced by:
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Assistant Director will send LPA Kaur a copy of staff members immunization records (MMR, Tdap, & influenza) no later than the due date of 09/9/22.
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Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facilty staff members did not have proof of immunization records.
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Type B
09/09/2022
Section Cited
CCR
101216(g)(1
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(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
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Assistant Director will send LPA Kaur a copy of staff members TB clearance, Health Screening Report (LIC 503) no later than the due date of 09/9/22.
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Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Multiple Staff members did not have Health Screening Report (LIC 503), multiple staff members did not have a proof of TB Clearance.
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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: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Simerjit KaurTELEPHONE: (510) 622-2632
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2