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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400493
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:47:23 PM

Document Has Been Signed on 02/29/2024 03:47 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 CENTERFACILITY NUMBER:
434400493
ADMINISTRATOR:GRAY, STACIEFACILITY TYPE:
850
ADDRESS:730 EMPY WAYTELEPHONE:
(408) 429-2683
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 57TOTAL ENROLLED CHILDREN: 55CENSUS: 34DATE:
02/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Stacie Gray-WalkerTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico conducted a Case Management Inspection in response to an unusual incident that was reported by the facility to Licensing on February 26, 2024. LPA met with Site Director, Stacie Gray-Walker, and explained the nature of today's visit. LPA toured the facility, reviewed a child's file, and obtained copies of documents.

Based on interviews, it was determined that on February 23, 2024, a child (C-1) got out the playground's gate unnoticed by staff to meet his parent who was walking towards the playground. A parent left the gate open and the child was able to get out.

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

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

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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 02/29/2024 03:47 PM - It Cannot Be Edited


Created By: Marilou Monico On 02/29/2024 at 03:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KIDANGO VALLEY MEDICAL CENTER
FACILITY NUMBER: 434400493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2024
Section Cited
CCR
101229(a)(1)

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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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By POC date: 03/01/24, Site Director agreed to submit a written plan of correction to ensure that children are supervised at all times.
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This requirement was not met as evidenced by: A child (C-1) got out the playground's gate unnoticed by staff to meet his parent who was walking towards the playground. 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 Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
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