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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410590
Report Date: 06/03/2022
Date Signed: 06/03/2022 09:16:52 AM


Document Has Been Signed on 06/03/2022 09:16 AM - 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:KINDERPLEX @ THE WETLANDSFACILITY NUMBER:
434410590
ADMINISTRATOR:SUBRAMANIAM, LATHAFACILITY TYPE:
830
ADDRESS:3801 EAST BAYSHORETELEPHONE:
(650) 605-9500
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:36CENSUS: 7DATE:
06/03/2022
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
07:57 AM
MET WITH:Katherine KohlmanTIME COMPLETED:
09:29 AM
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On 6/3/2022, Licensing Program Analyst (LPA) Jonathan Williams arrived to the facility unannounced for the purposes of conducting a Case Management visit in response to an unusual incident reported to the Department by facility staff. LPA was met by Katherine Kohlman (Operations Manager). Present for today's inspection were seven fingerprint cleared and associated staff members and seven children in care.

On 5/6/2022, facility staff reported an unusual incident to the Department. The report states that on 5/6/2022, facility staff propped open a classroom door leading into the outdoor activity area in order to cool down the classroom. A child in care (C1) then pushed open the door and went into the outdoor activity area, unnoticed by facility staff. C1 was left unsupervised in the outdoor activity area for about three minutes before facility staff noticed C1 outside and brought C1 back into the classroom.

Facility representative is advised that CCR 101229(a)(1) states the following:

"No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation."

Type A deficiency is cited pursuant to CCR 101229(a)(1). Facility representative was advised LIC9224 must be delivered to and signed by all current parents of children and parents of all children subsequently enrolled for a period of 12 months from today's date.

Roster obtained. Exit interview conducted. Appeal rights provided.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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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Document Has Been Signed on 06/03/2022 09:16 AM - 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: KINDERPLEX @ THE WETLANDS
FACILITY NUMBER: 434410590

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

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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 evidenced by:
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On 6/3/2022, a child was left unattended for approximately three minutes before being noticed by a staff member. This presents an immediate risk to the health and safety of 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: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
LIC809 (FAS) - (06/04)
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