434400052-1-4-2022-07-CC-MMOO-CACTG8-20220104134244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434400052
Report Date: 01/04/2022
Date Signed: 01/04/2022 01:42:52 PM

Document Has Been Signed on 01/04/2022 01:42 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:	KIDSPARK		FACILITY NUMBER:	434400052
ADMINISTRATOR:	ZEPEDA, CHRISTINA		FACILITY TYPE:	850
ADDRESS:	2858 STEVENS CREEK BLVD. #100		TELEPHONE:	(408) 985-2599
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 60	CENSUS: 18	DATE:	01/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Debbie Milner		TIME COMPLETED:	01:55 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) Marilou Monico met with Licensee, Debbie Milner, for an unannounced Required - 1 Year inspection. LPA toured the indoor areas. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus, current Fire Drill Log, and Activity Schedule. Days and hours of operation are Monday through Friday 8:00 AM to 7:00 PM, and Saturday from 10:00 AM to 9:00 PM. The facility serves children ages two years thru 11 years. Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. LPA reviewed 15 children's and four staff files (director, 3 teachers) during today's inspection. Each child's file reviewed contains the Identification and Emergency Information form (LIC 700) and required licensing forms. All staff files reviewed contain the required transcripts/verification of experience/immunization records, Personnel Record, Health Screening Report with TB test, Criminal Record Statement (LIC 508), and Employee Rights (LIC 9052), . All staff have current certificates of completion of the Mandated Reporter Training for Child Care Workers on file. Two staff members have current CPR and First Aid certifications on file. Debbie understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips). Parents/authorized representatives sign in and sign out the children. Continuation on next pages:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

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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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: KIDSPARK	FACILITY NUMBER: 434400052
	VISIT DATE: 01/04/2022

NARRATIVE

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LPA observed that the teacher/child ratio was in compliance during today's inspection. Debbie understands the
conditions, limitations, and capacity specifications of the Facility license. Debbie understands that children shall be
visually supervised at all times. Any child(ren) who exhibit symptoms of illness including, but not limited to, fever or
vomiting, are not accepted in care. Any child(ren) who become ill during the day, shall be isolated in a vacant on-limit area of the facility away from the other children.

LPA observed that the Facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. Debbie understands that the Facility must be kept free of flies and other insects & rodents. LPA observed that all furniture and equipment is in good condition and safe for the children. Drinking water is readily available for the children in the Facility via pitchers/disposable cups. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Debbie states that there are no weapons or firearms on the premises. The Facility has functioning smoke and carbon monoxide detectors indoors.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. The Facility has food preparation area with refrigerator, microwave, and a sink with hot and cold running water. The Facility provides morning and afternoon snacks. The Facility has trash can with tight fitting lid for solid waste. Cleaning supplies are inaccessible to the children and stored in high shelves inaccessible to children. LPA observed a complete First Aid kit, including touch less thermometer, in the Facility. LPA did not observe any bodies of water. Debbie states that the Facility does not provide transportation.

This facility is not providing Incidental Medical Services – IMS at this time. For IMS information see Evaluator Manual
- Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information
regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301
(voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the
ADA, available at: http://www.ada.gov/childqanda.htm.

Continuation on next page:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

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: KIDSPARK	FACILITY NUMBER: 434400052
	VISIT DATE: 01/04/2022

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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided.
Please complete the survey and share your inspection experience. If you have any questions regarding the process
or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the
inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/communitycare-
licensing/inspection-process.

As a result of this inspection, there were no deficiencies cited.

Exit interview conducted and report was reviewed with the Licensee, Debbie Milner.

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: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

LIC809 (FAS) - (06/04)

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