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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414162
Report Date: 04/07/2023
Date Signed: 04/07/2023 03:39:24 PM


Document Has Been Signed on 04/07/2023 03:39 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:SAFARI KIDFACILITY NUMBER:
434414162
ADMINISTRATOR:MUDDEEREGOWDA, RASHMIFACILITY TYPE:
850
ADDRESS:20100 STEVENS CREEK BLVDTELEPHONE:
(408) 253-3712
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:88CENSUS: 24DATE:
04/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Eva FernandezTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico made a Case Management Inspection in response to an Unusual Incident Report (LIC 624) received from the facility on March 31, 2023. LPA met with Site Director, Eva Fernandez, and explained the nature of today's inspection. LPA toured the facility, interviewed staff, and reviewed files.

Based on interviews and records review, it was determined that on March 28, 2023, C-1 was standing by the corner shelf and window in Room 3. C-1 tried to climb the window sill then slipped and bumped the left side of his mouth on the wood floor. C-1 sustained a cut on the upper lip. S-1 witnessed the incident. S-1 is a teacher's aide and was left alone supervising five toddlers including C-1 in Room 3. S-1 applied clean paper towel to hold the blood. S-1 called S-2 to assist. The Site Director was notified of the incident. The Site Director contacted 911 and parents were notified.

As a result of this inspection, deficiency was cited on the following page:

Exit interview was conducted and report was reviewed with Site Director, Eva Fernandez.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
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 04/07/2023 03:39 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: SAFARI KID
FACILITY NUMBER: 434414162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2023
Section Cited

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Responsibility for Providing Care and Supervision - (a)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 indicated that she will submit a written plan by 04/10/23 to ensure that a fully qualified teacher will be in the classroom to provide supervision to children.
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This requirement was not met as evidenced by: Based on interviews and records review, S-1 who is a teacher's aide was alone supervising five children in the toddler option Room 3 on March 28, 2023. This poses an immediate risk to the health, safety, and personal rights of children in care.
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Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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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) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2