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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415211
Report Date: 12/18/2019
Date Signed: 12/18/2019 01:11:44 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:KIDANGO ARBUCKLEFACILITY NUMBER:
434415211
ADMINISTRATOR:IRENE BURGOSFACILITY TYPE:
830
ADDRESS:1910 CINDERELLA LN, RM 165&166TELEPHONE:
(408) 258-3710
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY:32CENSUS: 29DATE:
12/18/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Irene BurgosTIME COMPLETED:
01:20 PM
NARRATIVE
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 LPA Janet Tse met with director Irene Burgos for a case management inspection. LPA observed 16 children with three teachers in Room 165 and 13 children with four teachers in Room 166.

Licensing was informed that the preschool was contacted by the San Jose Police Department a few months ago regarding an incident involving a child who was enrolled in the child care center. The contact from the police department was verified by the staffs. The director was aware of the police contact; but the incident was not reported to Licensing.

Deficiency was cited. Notice of site visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
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: KIDANGO ARBUCKLE
FACILITY NUMBER: 434415211
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/26/2019
Section Cited

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Reporting Requirements. ...Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours....
This requirement was not met as evidenced by:
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Licensing was informed that the preschool was contacted by the San Jose Police Department a few months ago regarding an incident involving a child who was enrolled in the child care center...the incident was not reported to Licensing./ This poses a potential risk to the Health, Safety, or 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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2019
LIC809 (FAS) - (06/04)
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