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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416145
Report Date: 01/10/2020
Date Signed: 01/10/2020 10:52:15 AM

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 ANDREW HILLFACILITY NUMBER:
434416145
ADMINISTRATOR:MAI TONFACILITY TYPE:
850
ADDRESS:3200 SENTER ROADTELEPHONE:
4089285211
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:27CENSUS: 21DATE:
01/10/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Angelica GalvanTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Dung Mac and Mel Matos conducted an Unannounced Case Management - Incident investigation inspection at the facility. LPAs met with Site Director, Angelica Galvan, and also interviewed her for this investigation. The purpose of the inspection was to review an unusual incident that occurred at the facility on 12/12/19. The facility reported the incident to Licensing via phone and fax on 12/13/19.

The unusual incident occurred on 12/12/19 at approximately 11:10 AM. One staff observed another staff grabbing a preschool child in the preschool playground, shaking the child a little, and raising the child's chin to get the child's attention. Angelica states that another staff observed the incident and immediately notified her of the incident. Angelica states that she and the witness staff checked the child and did not observe any marks on the child. Angelica states that she spoke with the accused teacher and suspended the staff pending further investigation. Angelica states that she also spoke with the child's mother and advised her of the incident and what actions the Facility was taking to address the matter.

Angelica provided LPAs with additional documentation, including witness statement, of the incident during today's inspection.

The following Type B deficiency is issued as a result of today's investigation inspection. LPAs conducted an exit interview with Angelica Galvan, director, and provided her with appeal rights prior to the conclusion of today's inspection.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020
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 ANDREW HILL
FACILITY NUMBER: 434416145
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2020
Section Cited

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PERSONAL RIGHTS: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature [...]
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This requirement is not met as evidenced by: a staff was witnessed grabbing/shaking and raising a child's chin to get the child's attention on 12/12/2019. This poses a potential health, safety, and personal right risk to daycare children.
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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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2020
LIC809 (FAS) - (06/04)
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