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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400493
Report Date: 09/28/2022
Date Signed: 09/28/2022 03:47:45 PM


Document Has Been Signed on 09/28/2022 03:47 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:KIDANGO VALLEY MEDICAL CENTERFACILITY NUMBER:
434400493
ADMINISTRATOR:GRAY, STACIEFACILITY TYPE:
850
ADDRESS:730 EMPY WAYTELEPHONE:
(408) 429-2683
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:57CENSUS: 23DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Stacie Gray-Walker & May ResurreccionTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Marilou Monico conducted an unannounced Required - 1 Year Inspection. LPA met with Site Director, Stacie Gray-Walker, and Master Teacher, May Resurreccion. Facility's License, Notification of Parents’ Right Poster, Child Car Seat Law, Personal Rights (LIC 613A), Emergency Disaster Plan, Menus, Activity Schedule, and Earthquake Preparedness Checklist were observed to be posted. The center's operating hours are Monday through Friday 06:30 AM to 6:00 PM. The preschool program utilized two classrooms. The facility serves children ages 2 years to entry into first grade.

LPA toured the facility both indoor and outdoor. LPA observed that the facility was operating in compliance with teacher to children ratio requirement. Furniture and equipment were observed to be age appropriate and in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, and other items that are dangerous to children were stored inaccessible to children. Floors were clean. LPA observed that the preschool children's bathroom is sanitary and operable. The bathroom has four toilets and four sinks. Stacie indicated that the center has third party cleaning service that comes after daycare hours to clean the facility.

Foods and beverages were kept protected against contamination and spoilage. Drinking water is available for the children indoor by pitchers and disposable cups. Trash cans for solid waste had tight-fitting covers on, and were in good repair. Fire extinguisher, working smoke and carbon monoxide detectors were observed.

Stacie stated that there are no firearms in the facility. Drinking water is readily available for the children outdoor by pitchers and disposable cups. The playground is surrounded by appropriate fencing and the outdoor surfaces are safe. Shades are provided by canopy, trees, and umbrella. LPA observed synthetic grass as resilient material under and around the climbing structure. There were no bodies of water observed.

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SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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: KIDANGO VALLEY MEDICAL CENTER
FACILITY NUMBER: 434400493
VISIT DATE: 09/28/2022
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LPA reviewed 10 children's files. Children records reviewed include Admission Agreement, Identification and Emergency Information, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, Physician's Report, Medical Assessment, Immunization, and TB test.

Nine (9) staff files were reviewed. Staff records reviewed include Criminal Record and Child Abuse Index Clearance, Personnel Record, Employee Rights, Statement Acknowledging Requirement to Report Child Abuse, Health Screening Report with TB Clearance, Immunizations (Measles, Pertussis, and Flu) and required Training. LPA reminded Site Director that the online AB1207 Mandated Reported Training needs to be renewed every two years. Site Director has current certification in Pediatric CPR and First Aid.

This facility provides Incidental Medical Services – IMS. Stacie stated that currently, there are no children using medication. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

Site Director 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.

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/community-care-licensing/process.

Continuation on next page:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: KIDANGO VALLEY MEDICAL CENTER
FACILITY NUMBER: 434400493
VISIT DATE: 09/28/2022
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The following item must be submitted to Licensing by October 28, 2022:
1) Designation of Facility Responsibility (LIC 308)

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

Exit interview conducted and report was reviewed with the Site Director, Stacie Gray-Walker.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3