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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406690
Report Date: 07/30/2024
Date Signed: 07/30/2024 03:25:28 PM

Document Has Been Signed on 07/30/2024 03:25 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KIDZ ACADEMY, INC.FACILITY NUMBER:
434406690
ADMINISTRATOR/
DIRECTOR:		CAROLYN MENDOZAFACILITY TYPE:
850
ADDRESS:1224 NORTH WINCHESTER BLVDTELEPHONE:
(408) 261-9523
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 43TOTAL ENROLLED CHILDREN: 38CENSUS: 23DATE:
07/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Carolyn MendozaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Mandeep Kaur met with Director, Carolyn Mendoza, for an unannounced case management inspection.

LPA interviewed the Director during today's inspection. Based on interviews and record reviews, facility failed to notify the department regarding an unusual incident that occurred on 07/25/2024 per Title 22 Regulations section code: 101212(d) Reporting Requirements: by telephone or fax within Department's next working day and during its normal business hours. Director stated that written LIC 624(Unusual Incident/injury report) for the incident that occurred on 07/25/2024 was mailed to the Department on 07/25/2024. Director stated that facility has not contacted the department via telephone or fax regarding the incident that occurred on 07/25/2024.

A Technical Violation was issued during today's inspection. Exit interview was conducted and reviewed with Director Carolyn Mendoza. No deficiencies were cited during today's inspection.

Notice of site visit was issued and must remain posted for 30 days.
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.

LIC809 (FAS) - (06/04)
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