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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430710584
Report Date: 05/13/2022
Date Signed: 05/19/2022 10:57:26 AM

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
03/14/2022 and conducted by Evaluator Elizabeth Larios
COMPLAINT CONTROL NUMBER: 07-CC-20220314155512
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 covered daycare child’s crib with a blanket.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Elizabeth Larios conducted an unannounced complaint investigation to deliver investigation finding. 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 allegation.

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.

Deficiency was cited today see attach LIC 9099-D. 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 3
Control Number 07-CC-20220314155512
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 3
Control Number 07-CC-20220314155512
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
101439.1(f)(3)
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101439.1 Infant Care Center Sleeping Equipment
(f)Cribs shall be free from all loose articles and objects, including blankets and pillows.
(3) There shall be no objects hanging above or attached to the side of the crib.This requirement was not met as evidenced by:


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Executive Director (ED) will read the infant sleeping regulations and send a sign statement that she understands the regulations. ED will also schedule a training with staff on Infant Care Center Sleeping Equipment and Proof of training submitted to CCL by POC date.
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Based on interviews, staff (S1) draped a blanket over infant (C1) crib while infant was in crib. 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 3