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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403618
Report Date: 03/05/2020
Date Signed: 03/05/2020 05:05:29 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:KINGDOM KREWFACILITY NUMBER:
434403618
ADMINISTRATOR:COLLEEN JONESFACILITY TYPE:
840
ADDRESS:1730 CURTNER AVENUETELEPHONE:
(408) 264-2811
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:116CENSUS: 45DATE:
03/05/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Valorie WilliamsTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management-Incident inspection. Upon arrival, LPA met with Lynell Frey and explained the reason for inspection. Director Valorie Williams arrived shortly after. The purpose of this inspection is the review an incident that was self-reported to the San Jose Regional office on 02/28/2020.

The incident occurred on 02/27/2020, which involved C-1 and an absence of supervision. Based on interview, C-1 was left unattended from about 3:20PM to 4:40PM. No injuries were obtained from this incident. C-1's parent was notified of the incident.

During this inspection, LPA toured the outside area including the parking lot. LPA also reviewed relevant documents. LPA interviewed staff and children. LPA discussed with Director Valorie about new procedures and protocols to ensure all children are accounted for and supervised at all time. Director stated that she conducted a staff meeting with all her staff to discuss the new procedures and protocols on 02/28/2020.

As a result of this investigation, a Type A deficiency has been cited and a civil penalty of $500 has been assessed for immediate $500. An exit interview was conducted where this report, citation, plan of correction, appeal rights, and civil penalty were discussed and provided to Director Valorie Williams.

LPA also discussed about AB 633 requirement to provided a copy of 809 report dated 03/05/2020 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 has been issued and must be posted for 30 consecutive days; along with the 809 report dated 03/05/2020.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020
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: KINGDOM KREW
FACILITY NUMBER: 434403618
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2020
Section Cited

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Responsibility for Providing Care and Supervision. No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation.
This requirement is not met as evident by:
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Based on interviews, Licensee did not ensure that all children were supervised at all time. This poses an immediate risk to the health and safety to the 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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2020
LIC809 (FAS) - (06/04)
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