<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406690
Report Date: 10/02/2023
Date Signed: 10/02/2023 04:00:42 PM


Document Has Been Signed on 10/02/2023 04:00 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:KIDZ ACADEMY, INC.FACILITY NUMBER:
434406690
ADMINISTRATOR:CAROLYN MENDOZAFACILITY TYPE:
850
ADDRESS:1224 NORTH WINCHESTER BLVDTELEPHONE:
(408) 261-9523
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:43CENSUS: 15DATE:
10/02/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Carolyn MendozaTIME COMPLETED:
03:30 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) Anna Morales conducted a Case Management- Lead Testing/Exceedance visit and met with Director Carloyn Mendoza and informed her the purpose of the visit.

LPA was informed that the first Lead Sample test was conducted on 7/15/2023. Level Exceedance(ALE) were found in two locations:. LPA was informed that these two faucets were capped and covered. Director stated that the children bring their own water bottles and have access to refills (filter and water bottles).

During today's inspection LPA Morales obtained the following documents; Self-Certification LIC9275, Sampling Checklist Form LIC9276, Facility Sketch LIC 999, fully labeled with locations of all water outlets, and full lead report.

One Type B deficiency was issued during visit, exit interview conducted, and a copy of this report was reviewed with the Director Carolyn Mendoza. Appeal rights were reviewed and provided.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/02/2023 04:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: KIDZ ACADEMY, INC.
FACILITY NUMBER: 434406690

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2023
Section Cited

101700.3(b)(1)

1
2
3
4
5
6
7
Lead Testing Written Directives (b)(1) a result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Fixtures B and D have been capped and disconnected after the initial lead testing report. Director stated that the children never used the fountains prior to testing.
8
9
10
11
12
13
14
Two fixtures reported an ALE of 5.5 parts per billion or greater in Fountains 27 (B) and 12 (D). This poses a potential risk to the health, safety, and personal rights of children in care.
8
9
10
11
12
13
14
Deficiency is cleared during today's visit.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2