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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430710584
Report Date: 05/13/2022
Date Signed: 05/13/2022 02:36:07 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2022 and conducted by Evaluator Elizabeth Larios
COMPLAINT CONTROL NUMBER: 07-CC-20220228101723
FACILITY NAME:KINDERWOOD CHILD DEVELOPMENT CENTER, INCFACILITY NUMBER:
430710584
ADMINISTRATOR:ULRICH, ELISEFACILITY TYPE:
830
ADDRESS:5560 ENTRADA CEDROSTELEPHONE:
(408) 363-1366
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:30CENSUS: 16DATE:
05/13/2022
UNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Elise Ulrich TIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff are propping bottles up for infants in the infant swings
Pacifiers are not sanitized properly
Formula in a partially consumed bottle is not being discarded
Formula is left out at room temperature more than 2 hours
Staff handle infants roughly
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Elizabeth Larios conducted an unannounced complaint investigation to deliver investigation findings. LPA met with Executive Director, Elise Ulrich (Ms. Lee) and explained the purpose of today's visit was to deliver the investigation finding for the above allegations.

Based on observation, record reviews, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited including a Type A deficiency on the attached LIC 9099-D. Copies of this report along with Type "A" deficiency to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility during the next 12 months.

Exit interview was conducted, where this report was reviewed and discussed with Elise Ulrich (Ms. Lee). Appeal rights were given. CONTINUE ON LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Elizabeth LariosTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
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 5
Control Number 07-CC-20220228101723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KINDERWOOD CHILD DEVELOPMENT CENTER, INC
FACILITY NUMBER: 430710584
VISIT DATE: 05/13/2022
NARRATIVE
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A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Elizabeth LariosTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 07-CC-20220228101723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KINDERWOOD CHILD DEVELOPMENT CENTER, INC
FACILITY NUMBER: 430710584
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
101427(h)
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101427 Infant Care Food Service (h) Infants who are unable to hold a bottle shall be held by a staff person or other adult for bottle feeding. At no time shall a bottle be propped for an infant. An infant shall not be allowed to carry a bottle while ambulatory. A bottle given to an infant able to hold his/her own bottle shall be unbreakable. This requirement was not met as evidenced by:
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Executive Director (ED) will review regulations and submit a letter of understanding and a plan for how this deficiency will be avoided in the future. ED will also schedule a training with staff on Infant Care Food Service. Proof of training submitted to CCL by POC date.
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Based on interviews, infants that cannot hold bottles are not being held by a staff person and bottles have been popped for feedings. This poses a potential risk to the health and safety of children in care.
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Type B
05/20/2022
Section Cited
CCR
101438.1(d)
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101438.1 Infant Care General Sanitation (d) Objects used by infants that are mouthed, shall be washed and disinfected at least daily, or more often if necessary. Such objects shall include, but not be limited to, toys and blankets. This requirement was not met as evidenced by:
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Executive Director (ED) will submit a written plan outlining how she will ensure infant pacifiers will be washed/disinfected, stored, and label with their name to CCL by POC date.
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Based on interviews, infant pacifiers were not being sanitized. This poses a potential risk to the health and safety of children in care.
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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 SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Elizabeth LariosTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 07-CC-20220228101723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KINDERWOOD CHILD DEVELOPMENT CENTER, INC
FACILITY NUMBER: 430710584
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
101427(d)(1)
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01427 Infant Care Food Service
(d) The infant care center shall provide only commercially prepared formulas for infants. (1) Commercial formulas shall be stored and prepared in accordance with label directions.This requirement was not met as evidenced by:
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Executive Director (ED) will review regulations and submit a letter of understanding and a plan for how this deficiency will be avoided in the future. ED will also schedule a training with staff on Infant Care Food Service. Proof of training submitted to CCL by POC date.
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Based on interviews, partially consumed bottle is not being discarded and left out at room temperature more than two hours. This poses a potential risk to the health and safety of children in care.
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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 SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Elizabeth LariosTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 07-CC-20220228101723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KINDERWOOD CHILD DEVELOPMENT CENTER, INC
FACILITY NUMBER: 430710584
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2022
Section Cited
CCR
101223(a)(3)
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101223 Personal Rights (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as evidenced by:

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Executive Director (ED) will submit a written plan outlining how she will ensure that children's personal rights are not violated. ED will also schedule a training with staff on Personal Rights. Proof of training submitted to CCL by POC date.

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Based on interviews, staff (S1) handle infant (C1) roughly and force feed infant. This poses an immediately risk to the health and safety of children in care.
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AB633 Parent Notification is required. According to AB 633, all parents of children currently enrolled and any future children being enrolled for the next 12 months must be provided with this report which contains this type A deficiency.
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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 SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Elizabeth LariosTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5