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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434406690
Report Date: 07/30/2024
Date Signed: 07/30/2024 03:21:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2024 and conducted by Evaluator Mandeep Kaur
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240725162922
FACILITY NAME:KIDZ ACADEMY, INC.FACILITY NUMBER:
434406690
ADMINISTRATOR:CAROLYN MENDOZAFACILITY TYPE:
850
ADDRESS:1224 NORTH WINCHESTER BLVDTELEPHONE:
(408) 261-9523
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:43CENSUS: 23DATE:
07/30/2024
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Carolyn MendozaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide adequate supervision to daycare children.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mandeep Kaur conducted an unannounced complaint investigation. LPA met with Director, Carolyn Mendoza and discussed the complaint allegation with Director. LPA toured the indoor and outdoor area of the facility, reviewed a staff (S1) file for teacher qualifications, reviewed two (2) children (C1 and C2) files, and interviewed Director during today's investigation. During today's investigtion, LPA also reviewed the camera video clip where two children are walking out of the facility outside on 07/25/24 about 12:30pm.

Director, Carolyn Mendoza self-admitted to LPA that on 07/25/24, about 12:30pm, one of the child (C1) was found outside of the facility, next to the office outside and second child (C2) was found by the street (Winchester Blvd). Director states that staff (S1) did not pay attention to how children (C1 and C2) left the facility while being in the playarea and staff (S1) was gathering other children to go use the bathroom.

Copy of the child facility roster, Personnel Report, written Unusual Incident/injury report and copy of the video clip was obtained during today's investigation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 07-CC-20240725162922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIDZ ACADEMY, INC.
FACILITY NUMBER: 434406690
VISIT DATE: 07/30/2024
NARRATIVE
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Based on record reviews, interviews and evidence gathered during the investigation process, the Department concludes that staff did not provide adequate supervision to daycare children. Therefore, the above allegation is SUBSTANTIATED, meaning the allegation is valid because the preponderance of the evidence standard has been met.

As a result of this investigation, a Type A deficiency is being cited on the attached LIC 9099D form and an immediate civil penalty is assessed in the amount of $500. Appeal rights given and exit interview conducted with Director, Carolyn Mendoza.

Notice of Site Visit was issued. Notice of Site Visit along with a copy of today's report dated (07/30/2024) and the Type A citation shall remain posted in a visible location of the Facility for 30 consecutive days.

LPA also informed Director that they must provide a copy of this licensing report dated (07/30/2024) that documents today's Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the child(ren) are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report(LIC 9224) must be placed in the child's file.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 07-CC-20240725162922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: KIDZ ACADEMY, INC.
FACILITY NUMBER: 434406690
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2024
Section Cited
CCR
101229(a)(1)
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Responsibility for Providing Care and
Supervision: 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... Supervision shall include visual observation.
This requirement was not met as evidenced by:
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Director stated that she is going to submit a written plan of correction by July 31, 2024 to the Department. Director stated that training to the staff will be conducted regarding supervision and safety of the children on 08/02/24 and Director will provide the attendees attendance sheet with topics and date of the training.
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Based on interviews,record reviews and evidence gathered, two of the children were found outside of the facility alone without any supervision on 07/25/2024 about 12:30PM. This poses an immediate risk to the health, safety and personal rights of children in care.
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Licensee must provide copies of this report to
parents/guardians of children in care at this
facility and to parents/guardians of children
newly enrolled at this facility during the next 12
months per the AB633 requirements.
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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.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3