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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406751
Report Date: 07/11/2023
Date Signed: 07/11/2023 10:42:06 AM


Document Has Been Signed on 07/11/2023 10:42 AM - 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:KIDANGO ARBUCKLEFACILITY NUMBER:
434406751
ADMINISTRATOR:LINDSAY MASUDAFACILITY TYPE:
850
ADDRESS:1910 CINDERELLA LANETELEPHONE:
(408) 905-8985
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY:40CENSUS: 30DATE:
07/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Lindsay MasudaTIME COMPLETED:
10:41 AM
NARRATIVE
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On 7/11/2023 LPA Pete Hernandez made an unannounced Case Management - Incident Visit to the facility in response to an incident that occurred on 6/28/2023. LPA met with Preschool Director Lindsay Masuda and explained the purpose of the visit. LPA toured the facility and interviewed staff, LPA learned that on 6/28/2023 at approximately 8:01AM a preschool child had run out of the classroom's rear entrance and the Teacher left the classroom to run after the child. She left the 6 children unsupervised in the classroom for approximately 30 seconds. The staff immediately recovered the child (C1) and returned to the classroom.

LPA inspected the physical plant. LPA interviewed staff. LPA also reviewed incident report and collected a copy of the childrens roster.

There is an issuance of Type A citations today, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is being cited based on the LPAs observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D, An exit interview was conducted, and Plan of Corrections were reviewed and developed with the licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Lindsay Masuda, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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 07/11/2023 10:42 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: KIDANGO ARBUCKLE
FACILITY NUMBER: 434406751

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2023
Section Cited
CCR
101229(a)(1)

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Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). This requirement is not met as evidenced by:
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By POC date: Program Director shalll submit a detailed plan to ensure that children are supervised at all times.
Since this is a zero-tolerance violation, an immediate civil penalty of $500 was assessed during the inspection.
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LPA's observation, interviews conducted, and record review during the investigation it was determined that the Teacher had left 6 preschoolers unsupervided in the classroom when she ran after a child who ran out of the classroom. This poses an immediate risk to the health and safety of the children in care.
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Upon receipt, licensee shall post and provide copies of this licensing report,and have LIC 9224 signed and kept on file, 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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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