434400492-6-26-2024-07-CC-MMOO-D6LUV6-20240626155439

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434400492
Report Date: 06/26/2024
Date Signed: 06/26/2024 03:56:31 PM

Document Has Been Signed on 06/26/2024 03:56 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:	KIDANGO VALLEY MEDICAL CENTER		FACILITY NUMBER:	434400492
ADMINISTRATOR:	GRAY, STACIE		FACILITY TYPE:	830
ADDRESS:	730 EMPEY WAY		TELEPHONE:	(408) 429-2683
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	13	CENSUS: 4	DATE:	06/26/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:44 AM
MET WITH:	Stacie Gray		TIME COMPLETED:	12:10 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	Licensing Program Analysts (LPAs) Marilou Monico and Jen Beehler met with Site Director, Stacie Gray, for an unannounced Annual Random Inspection. The purpose of today's inspection was explained with Stacie. Facility's License, Notification of Parents’ Right Poster, Child Car Seat Law, Personal Rights (LIC 613A), Emergency Disaster Plan, Menus, Activity Schedule, and Earthquake Preparedness Checklist were observed to be posted. The center's operating hours are Monday through Friday from 06:30 AM to 6:00 PM. The facility is licensed to serve children ages 0 to 2 years old in the Infant/Toddler Room. LPAs toured the indoor and outdoor areas. LPAs observed that the teacher-child ratio was in compliance. Fire drill was conducted on June 25, 2024. The facility has current children's roster and a copy was provided to LPAs during the inspection. Cleaning products, disinfectants, sharp objects were stored inaccessible to children. Furniture and equipment were observed to be age appropriate and in good condition. The facility is clean and orderly. The bathrooms for staff are clean, sanitary, and operable. Site Director stated that the center has a third party cleaning service that comes and clean the facility after daycare hours. The center provides breakfast, lunch, and afternoon snacks to the children and catered to the center from Kidango Main Kitchen located in Fremont, CA. There is a kitchen at the facility. The kitchen is equipped with refrigerator, microwave, dishwasher, storage space for food, and a sink with hot and cold running water. Drinking water is available for the children indoor via individual water bottles. LPAs observed trash cans with tight fitting covers for the disposable of solid wastes and diapers. The facility has fire extinguishers and working smoke and carbon monoxide detectors. LPAs observed diaper changing table within arm's reach of a sink in the Infant/Toddler Room. *Continuation on next pages:*

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

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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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 VALLEY MEDICAL CENTER	FACILITY NUMBER: 434400492
	VISIT DATE: 06/26/2024

NARRATIVE

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The playground is surrounded with appropriate fencing and the outdoor surfaces are safe. Shade is provided by trees and canopy. Drinking water is readily available for the children outdoor via drinking fountains, water jug and cups. LPAs observed climbing structure with resilient material (synthetic grass) under and around the structure. There were no bodies of water observed. Stacie stated that there are no we weapons or firearms on the premises.

LPAs reviewed seven (7) children's files. Children records reviewed include Admission Agreement, Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Physician's Report, TB test, Immunizations, Parent Right's Receipt, Personal Rights, Pre-Admission Health History, and nap log. LPAs observed that three (3) children are missing up to date Infant Needs and Services Plan. Based on record review, 7 out of the 7 children enrolled and attending the infant program are over 2 years old. Site Director stated that due to developmental needs, the 7 children are not developmentally ready to attend the preschool program and have to remain in the infant program.

LPAs reviewed two (2) staff files. Staff records reviewed include Employee Rights, Statement Acknowledging Requirement to Report Child Abuse, Health Screening Report with TB Clearance, Immunizations (Measles, Pertussis, and Influenza) and required training. LPAs reminded Site Director that the Mandated Reporter Training shall be renewed by all staff every two years. At least one staff member present during the inspection has current Pediatric CPR/First Aid certifications.

This facility provides Incidental Medical Services – IMS. Site Director stated that currently, they don't have children in the infant program using any medication. LPAs reviewed storage of medication and reviewed 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/resources/child-care-centers/.

Site Director, Stacie Gray, was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

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 VALLEY MEDICAL CENTER	FACILITY NUMBER: 434400492
	VISIT DATE: 06/26/2024

NARRATIVE

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LPA discussed the safe sleep regulations with Site Director, Stacie Gray, and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPAs also informed Site Director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

For child care center licenses issued after July 1, 2022, the licensee shall test their water for
lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-
CCP).

LPAs verified that the lead testing was completed in accordance to the Written Directives
outlined in PIN 21-21.1-CCP.

Site Director, Stacie Gray, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&R's) throughout California.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Continuation on next page:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

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 VALLEY MEDICAL CENTER	FACILITY NUMBER: 434400492
	VISIT DATE: 06/26/2024

NARRATIVE

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The following items to be sent to Licensing by 07/26/24:
1) Board Resolution
2) Paperwork for the new Licensee Representative: Applicant Information (LIC 215), health screening with TB test, Mandated Reporter Training certificate, immunizations (measles, pertussis, and flu), and Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), orientation certificates (Application and Operations/Record Keeping) for Child Care Center.

As a result of this inspection, Type B deficiencies were cited.

Exit interview conducted and report was reviewed with Site Director, Stacie Gray.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/26/2024 03:56 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: KIDANGO VALLEY MEDICAL CENTER	FACILITY NUMBER: 434400492
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101419.3(a)

Modifications to Infant Needs and Services Plan

(a) The written infant needs and services plan shall be updated at least quarterly, or as often as necessary to assure its accuracy. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 7 children which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	Site Director stated that she will submit an updated Infant Needs and Services Plan for the three children by 07/10/24.

Type B

Section Cited

CCR

101361(a)

Limitations on Capacity and Ambulatory Status (a) It shall be permissible for a child whose developmental needs require continuation in an infant care center to remain in an infant care center up to a maximum age of three years. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 7 out of 7 children which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	Site Director stated that due to developmental needs, the seven children are not developmentally ready to attend the preschool program and have to remain in the infant program. Stacie stated that she will submit a written plan and assessment documents to Licensing by 07/10/24.

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 Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

LIC809 (FAS) - (06/04)

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