430702131-5-3-2019-07-CC-SYIP-BBTS53-20190503133339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430702131
Report Date: 05/03/2019
Date Signed: 05/03/2019 01:33:51 PM

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 KOUNTRY		FACILITY NUMBER:	430702131
ADMINISTRATOR:	CHRISTINE BELTRAN		FACILITY TYPE:	850
ADDRESS:	2715 SOUTH WHITE ROAD		TELEPHONE:	(408) 270-2560
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	144	CENSUS: 92	DATE:	05/03/2019
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Kristen Hendrix		TIME COMPLETED:	01:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Samantha Yip and Licensing Program Manager (LPM) Mary Segura conducted an unannounced case management-other. LPA and LPM met with Director Kristen Hendrix and explained the reason for the inspection. The purpose of this inspection is to obtain updated information regarding areas to be licensed as the preschool on the church campus. Facility previously submitted a request to change name from Kiddie Kountry to East Valley Christian Preschool. Currently, the facility is operating in the K111 to K114, the front reception, and Playground A. Director stated they would like to add Playground B located across the parking lot from the front reception area. Please note Playground A is being shared with church's elementary school and preschool is going to submit a waiver for shared playground space for both Playground A and Playground B. The measurement for Playground A and B are as following: Playground A: 69x33.250 + 21.833x87.167 + 56x21.833 + 3.417x39.333 + 11.917x32.833 + 84.167x4.500 + 8x18.167= 6,469.772 minus 166.562 (encumbered space) = 6,303.210 Playground B: 83.333x77.750= 6,479.140 6,303.210 + 6,479.140= 12,782.350 Total measurement: 12,782.350 sq. ft. divided 75 = 170 children

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 KOUNTRY	FACILITY NUMBER: 430702131
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/04/2019 Section Cited CCR 101170(e)(1)	1 2 3 4 5 6 7	Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evident by:	1 2 3 4 5 6 7	By POC 05/04/2019, Director stated that she will submit a written plan which outlines the schedule of fingerprint cleared staff who will stay with any adults who are providing extracurricular class to the
	8 9 10 11 12 13 14	Based on observation and record review, A-1 was observed to outside with 5 preschool children without the direct supervision of a person with criminal record clearance and A-1 did not possess criminal record clearance of their own. This poses an immediate risk to the health and safety to the children in care.	8 9 10 11 12 13 14	children in care.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 KOUNTRY	FACILITY NUMBER: 430702131
	VISIT DATE: 05/03/2019

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LPA and LPM observed that A-1 took 5 children out to the parking lot to do an extracurricular without direct supervision of a fingerprint cleared and fully qualified staff. A-1 is fingerprinted through the program their are hired through; however, A-1 is not cleared through the Department.

In the areas that were evaluated today, a Type A deficiency was cited and a civil penalty was assessed of $100 for caregiver background check. An exit interview was conducted with Director Kristen Hendrix, where this report, the citation, plan of correction, appeal rights, and civil penalties were discussed and provided to Director.

LPM also discussed about AB 633 requirement to provided a copy of 809 report dated 05/03/2019 and obtain a signed copy LIC 9224 for each child in care within one business days. LPA also discussed with Director that a copy of this report and a signed copy of LIC 9224 is required for any newly enrolled children within the 12 month period. LPA provided a copy of LIC 9224 and fact sheet to Director.

A Notice of Site Visit was issued and must be posted for 30 consecutive days; along with a copy of 809 report.

Director stated that she will submit the following to Licensing office by 06/03/2019:
1. updated LIC 200A to included the classroom numbers, playground, and other common used space (ig: office space) in box 6 that will be used for the preschool
2. updated LIC 600: floor plan
3. waiver request to share Playground A and Playground B with the elementary school
4. copy of the Bylaw with proof of being filed with California Secretary of State

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019

LIC809 (FAS) - (06/04)

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