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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403524
Report Date: 12/09/2021
Date Signed: 12/09/2021 04:01:41 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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
434403524
ADMINISTRATOR:AMANDA HERNANDEZFACILITY TYPE:
850
ADDRESS:1155 EAST ARQUES AVENUETELEPHONE:
(408) 245-3276
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY:146CENSUS: 76DATE:
12/09/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Amanda "Mandy" HernandezTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Mel Matos conducted an unannounced case management inspection and met with Amanda "Mandy" Hernandez. Purpose of today's inspection: self reported unusual incident that occurred at the Facility on October 28, 2021.

Mandy states that a preschool child bumped her upper left arm area into one of the poles of the play structure (near the slide area) while running in the preschool playground on October 28, 2021. The incident was observed by the child's teacher at 11 AM and the child did not require any medical attention as a result of the incident. Mandy states that the child was at the Facility until 3:50 PM that afternoon (until pick up time) and did not complain of any pain or discomfort to the upper left arm of her body. Mandy states that the child's mother called the Facility later that day and indicated that the child was in pain. Mandy states that the child's mother ended up taking the child to the doctor later that evening and the child was diagnosed with a cracked left clavicle. Mandy states that the child's mother also told her that the child had to be in sling for six weeks as a result of the cracked left clavicle.

LPA toured the preschool playground during today's inspection. LPA observed the play structure is safe and secure for the preschool children. LPA observed that the pole of the play structure (near the slide area) where the child bumped into is made of a rounded "hard plastic" material that is appropriate for the play structure.

Based on the available evidence, it is concluded that a child did sustain an injury as a result of bumping into a pole of the play structure; however, there is no evidence to substantiate that any licensing regulation(s) was violated as a result of the incident. Therefore, no deficiencies issued.

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: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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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