434403618-6-29-2021-07-CC-SYIP-C4FTA5-20210629143258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434403618
Report Date: 06/29/2021
Date Signed: 06/29/2021 02:33:12 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 KREW		FACILITY NUMBER:	434403618
ADMINISTRATOR:	VALORIE WILLIAMS		FACILITY TYPE:	840
ADDRESS:	1730 CURTNER AVENUE		TELEPHONE:	(408) 264-2811
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	116	CENSUS: 32	DATE:	06/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:19 AM
MET WITH:	Valorie Williams		TIME COMPLETED:	01:19 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 Analysts (LPAs) Samantha Yip and Ofelia Calivo conducted an unannounced Required- 1 Year inspection. LPAs met with Director Valorie Williams and explained the reason for the inspection. Present during today's inspection were 32 children and at least 4 staff. Facility was in ratio during today's inspection. LPA observed that staff went into adjacent room, where they could not visually supervise children in the other room. LPA reminded Director that staff need to be positioned where they can visually supervise children at all children. Staff re-positioned themselves where they can see children in both classrooms. There a board to post required postings. Facility uses an electronic sign in/sign out. LPAs reviewed electronic sign in/sign out. There is working phone on the facility. LPAs toured the inside and outside of the facility with Director Valorie Williams. The facility was observed to be clean. LPA reminded Director that any items that state to keep out of reach of children need to be inaccessible. LPAs observed that there was a bottle of bleach in a cabinet with a latch and a bottle of Glad air fresher in the bathroom. Director moved bottle on top of the cabinets and the Glad air fresher to an upper cabinet, where it is inaccessible to children. All other cleaning supplies were inaccessible to children. There is sufficient amount of age appropriate toys and equipment for children. Director stated that there are no weapons, such as firearms, stored on the premise. There a fire extinguisher, smoke detector, and a carbon monoxide detector. The outside activity area is fenced. Areas around play structure have resilient material. LPAs observed that the tan bark is starting to get low. LPAs reminded Director to ensure that any areas around the play structure or swings have resilient material. Director stated that they are going to be purchasing more tan bark and will send proof to Licensing. Shaded rest area is provided through building overhang and trees. There were no bodies of water observed during today's inspection. ----------------------CONTINUES ON 809 DATED 06/29/2021 PAGE 2-----------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

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
	VISIT DATE: 06/29/2021

NARRATIVE

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---------------------CONTINUATION OF 809 DATED 06/29/2021 PAGE 1---------------------
Facility only provides snacks to the children. Menu was observed to be posted. All meals are prepared and brought from home. Drinking water is provided through water fountains. Director stated that they are administering Incidental Medical Services (IMS) at this time. All medication are in their original packaging and have parent consent. LPA reminded Director to check expiration dates on all medication.

10 children's file were reviewed. The records reviewed include but not limited to Emergency Contact Card.

Three (3) staff files were also reviewed. The records reviewed include but not limited to Mandated Reporter training and immunization records. LPA discussed with Director about name on form are consistent and match. LPA observed that facility name on forms did not match facility name. Director stated that she will have staff re-fill out forms. LPA also discussed with Director that Health Screening and TB test need to be within one year of employment. LPA observed that S-1 and S-2 had the Health Screening and TB test on file, but was more than a year since date of employment. Director stated that she will have S-1 and S-2 obtain an updated Health Screening and TB test. LPA also observed that S-3 did not have updated Mandated Reporter Training. Director stated that she will submit updated Mandated Reporter training to Licensing.

All staff present during today's inspection have cleared criminal record and child abuse index. LPA also reminded Director of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

In the areas evaluated during today's inspection, a Type B citation was issued. An exit interview was conducted where this report, citation, plan of correction, and appeals rights were discussed and provided to Director Valorie Williams. A Notice of Site Visit has been issued and must be posted for 30 days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

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: KINGDOM KREW	FACILITY NUMBER: 434403618
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/06/2021 Section Cited	1 2 3 4 5 6 7	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 was not met as evident by:
	8 9 10 11 12 13 14	Based on observation, LPAs observed that staff went into adjacent class, where they could not visually supervise children in the other room. This poses a potential risk to the health and safety to the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC809 (FAS) - (06/04)

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