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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413043
Report Date: 04/05/2024
Date Signed: 04/05/2024 04:12:48 PM


Document Has Been Signed on 04/05/2024 04:12 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:SAFARI KID - SUNNYVALEFACILITY NUMBER:
434413043
ADMINISTRATOR:RAMAKRISHNAN, SUHASINIFACILITY TYPE:
850
ADDRESS:1271 WEST EL CAMINO REALTELEPHONE:
(650) 962-1366
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:100CENSUS: 30DATE:
04/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Guadalupe RodriguezTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mandeep Kaur and Marilou Monico conducted an unannounced Case Management-Incident inspection. LPAs met with Site Director Guadalupe Rodriguez and explained the reason for the inspection. The purpose of this inspection is to review a self-reported incident that occurred on 03/25/2024 regarding injury to a child. Incident was self reported to the San Jose Regional office on 03/27/2024.

During today's inspection, LPAs interviewed three of the staff and the Site Director. Two of the staff files were reviewed.

Based on interviews, children were left alone with an unqualified staff (S1) at the facility on March 25, 2024 and parents were not informed immediately regarding an injury.

Director and staff stated that the training on supervision and children safety was provided on March 29, 2024 to the staff and one on one training separately with the individual staff involved.

As a result of this inspection, Type A and Type B citations were issued. Exit interview conducted and report was reviewed with Site Director, Guadalupe Rodriguez. A notice of site visit has been issued and must remain posted for 30 days.

LPAs informed Site Director that this report dated 04/05/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Assembly bill 633 was provided and discussed with Site Director. LPAs informed the Site Director to provide a copy of this licensing report dated 04/05/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224), or other written statement, must be placed in the child's file for verification.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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 04/05/2024 04:12 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: SAFARI KID - SUNNYVALE
FACILITY NUMBER: 434413043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the children's needs.(1)No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Site Director stated that she is going to submit a written plan of correction by April 8, 2024 to the Department. Site Director stated that training to the staff was conducted regarding supervision and safety of the children on March 29, 2024.
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This requirement was not met us evidenced by: Based on interviews, children were left alone with an unqualified staff (S1) at the facility on March 25, 2024. This poses an
immediate risk to the health, safety and
personal rights 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: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/05/2024 04:12 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: SAFARI KID - SUNNYVALE
FACILITY NUMBER: 434413043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2024
Section Cited
CCR
101226(a)

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Health-Related Services; The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch. The licensee shall obtain specific instructions from the authorized representative regarding action to be taken.
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Site Director stated that she is going to submit a written plan of correction by April 10, 2024 to the Department regarding when to report an injury of a child to the parents/authorized representative.
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This requirement was not met us evidenced by: Based on interviews, parents were not informed immediately regarding an injury to a child on March 25, 2024. This poses a potential risk to the health, safety and personal rights 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: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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