434412724-6-9-2021-07-CC-MMOO-C3U289-20210609170957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434412724
Report Date: 06/09/2021
Date Signed: 06/09/2021 05:10:07 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:	KIDDIE ACADEMY OF CUPERTINO		FACILITY NUMBER:	434412724
ADMINISTRATOR:	XIONG, ANGELA		FACILITY TYPE:	840
ADDRESS:	19875 STEVENS CREEK BLVD		TELEPHONE:	(408) 517-0454
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	22	CENSUS: 5	DATE:	06/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Kathy Mae Sana		TIME COMPLETED:	05:20 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	#2 Licensing Program Analysts (LPAs) Marilou Monico and James Santos conducted an unannounced Annual inspection. LPAs met with Interim Director, Kathy Mae Sana, and informed her the purpose of the visit. Facility's License, Notification of Parents’ Right Poster, Child Car Seat Law, Personal Rights (LIC 613A), Emergency Disaster Plan, and Earthquake Preparedness Checklist were observed to be posted. The center's operating hours are Monday through Friday 07:00 AM to 06:30 PM. Age serve is Kindergarten to 13 years old. The School Age Program is operating in Rooms 6. The preschool and school age programs share the same playground at different times. LPAs toured the facility both indoor and outdoor. LPAs observed that the facility was operating in compliance with teacher to children ratio requirement. Children were engaged in activities under the supervision of the teacher. The classroom, restroom, and storage areas were inspected. There were no bodies of water observed. Interim Director stated that facility do not have weapons on the premises. Furniture and equipment were observed to be age appropriate and in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, poisons, and other items that are dangerous to children were stored inaccessible to children. Restroom for children to use were observed to be in operating conditions. Floors were clean. Outdoor activity space is enclosed by fencing and is observed to be free of hazards. LPAs observed play equipment were in good condition and areas around high climbing equipment have resilient material to absorb falls. Drinking water was readily available to children indoor and outdoor. Activities schedule and Menu were posted. Facility provides lunch and snacks (morning and afternoon). Lunch and snacks are prepared at the facility. . LPAs observed that food storage areas were clean and free of litter.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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: KIDDIE ACADEMY OF CUPERTINO	FACILITY NUMBER: 434412724
	VISIT DATE: 06/09/2021

NARRATIVE

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Foods and beverages were kept protected against contamination and spoilage. Trash cans for solid waste had tight-fitting covers on, and were in good repair. First Aid Kit was inspected. Fire extinguisher, smoke and carbon monoxide detectors were observed.

This facility is providing Incidental Medical Services – IMS Plan. LPAs reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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.

LPAs reviewed sign in and out record, and procedure. A sampling of children and staff files was taken for review during today's inspection. Children records reviewed include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, Medical Assessment and Immunization.

Staff records reviewed include Criminal Record and Child Abuse Index Clearance, Health Screening Report with TB Clearance, Immunization (Measles, Pertussis, and Flu) record and required Training. LPA reminded Interim Director that the online AB1207 Mandated Reported Training needs to be renewed every two years. Teacher and Interim Director who are present during the physical plant inspection have the required qualifying education credits and experience. There was at least one person with current certification in Pediatric CPR and First Aid present at the facility.

LPAs reminded Interim 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. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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: KIDDIE ACADEMY OF CUPERTINO	FACILITY NUMBER: 434412724
	VISIT DATE: 06/09/2021

NARRATIVE

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LPAs also reviewed with Interim Director the violations that would result in an immediate assessment of civil penalty in the amount of $500. Site Director is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.

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

A copy of this report was provided to the facility at the conclusion of the inspection.

NOTICE OF SITE VISIT WAS ISSUED. INTERIM DIRECTOR WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC809 (FAS) - (06/04)

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