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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400493
Report Date: 07/31/2024
Date Signed: 07/31/2024 03:11:29 PM

Document Has Been Signed on 07/31/2024 03:11 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/
DIRECTOR:		GRAY, STACIEFACILITY TYPE:
850
ADDRESS:730 EMPY WAYTELEPHONE:
(408) 429-2683
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 57TOTAL ENROLLED CHILDREN: 56CENSUS: 44DATE:
07/31/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:38 PM
MET WITH:Stacie GrayTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico met with Site Director, Stacie Gray, for a Case Management Inspection in response to an incident that was self-reported by the facility to Licensing on July 25, 2024 involving a daycare child, C-1. LPA toured the facility and interviewed staff.

Based on the information gathered during the investigation process, LPA learned that on July 24, 2024, staff (S-2 & S-3) in the Preschool Room (Room 89) were unaware that daycare child, C-1, left the room and went to the adjacent classroom (Infant/Toddler Room). C-1 was alone in the Infant/Toddler Room when she was found by a staff, S-1. S-1 brought C-1 back to Room 89.

A chime that is loud enough to be heard by staff was installed on the door between Room 89 and Infant/Toddler Room. LPA observed that all doors at the facility have chimes except the Director's Office. Site Director met with the staff in Room 89 on the same day of the incident and discussed about the importance of name to face check, providing children's supervision, head counting, and keeping the door closed at all times. S-2 received a written warning.

As a result of this inspection, Type A deficiency was cited on the following page.

Assembly Bill (AB) 633 was provided and discussed with Site Director. LPA informed the Site Director to provide a copy of this licensing report dated 07/31/24 that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to parents/guardians of any newly enrolled children for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224) must be placed in the child's file for verification.

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

A Notice of Site Visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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 07/31/2024 03:11 PM - It Cannot Be Edited


Created By: Marilou Monico On 07/31/2024 at 02:08 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: 07/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2024
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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Site Director states that by POC due date: 08/01/24, she will submit a detailed plan on how staff will maintain adequate supervision of children at all times.
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This requirement was not met as evidenced by: A daycare child, C-1, was found by a staff, S-1, unattended in the Infant/Toddler Room. This poses an immediate risk to the health, safety, and personal rights of children in care.
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Because the facility has been cited for repeating the same violation within 12 months, an immediate civil penalty of $1000 was assessed. Civil penalty of $100 per pay continues until the violation is corrected.

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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: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
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