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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434406754
Report Date: 10/18/2023
Date Signed: 10/18/2023 04:23:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 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
08/25/2023 and conducted by Evaluator Yangcheng Huang
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230825164728
FACILITY NAME:KIDANGO GOSS CENTERFACILITY NUMBER:
434406754
ADMINISTRATOR:KELLY ARANAFACILITY TYPE:
850
ADDRESS:2475 VAN WINKLE LANETELEPHONE:
(408) 353-0528
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY:22CENSUS: 7DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Sandra VillegasTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Lack of supervision led to child injury
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Oscar Huang and Sheena Chin met with Teacher, Sandra Villegas for subsequent complaint investigation to the facility to deliver findings on the above allegation.

LPAs conducted interviews with director, staff, children in care, as well as reviewed unusual incident report, and children records during the investigation of the allegation. On 08/18/2023, at the time the incident occurred there were two staff supervised 8 children. According to statement of confidential interviews with staff, LPAs learned that one staff was preoccupied by working with other children in separate location, and the other staff was preparing activity materials without witnessing C1's fall while C1 was playing magnetic tiles with C2, and fell, and sustained injuries to C1's back of head.

Continue to next page LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
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-20230825164728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GOSS CENTER
FACILITY NUMBER: 434406754
VISIT DATE: 10/18/2023
NARRATIVE
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Continue from LIC 9099 -

LPAs conclude that based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Teacher, Sandra was informed that civil penalties may be assessed by the department determined that any violation resulted into injury of a person in care, and/or failure to correct the deficiency.

LPAs advised Teacher, Sandra that a schedule informal meeting may be held at the San Jose Regional office to discuss the deficiency.

LPAs noticed Director, Kelly has submitted CCL plan of correction in written indicating methods and procedures implemented to ensure the facility stays in compliance with Tittle 22, Care and Supervision regulations, as well as held a title 22 supervision training focus on supervision and visual observation for all staff to ensure this will not occurred going forward with a copy of agenda including names and signatures of staff of attendance.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 07-CC-20230825164728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GOSS CENTER
FACILITY NUMBER: 434406754
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2023
Section Cited
CCR
101229(a)(1)
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Responsibility for Providing Care and Supervision - 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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Plan of Correction was submitted to the officein in written indicating methods and procedures implemented to ensure the facility stays in compliance with Tittle 22, Care and Supervision regulations, as well as a staff meeting/training was condcuted focusing on supervision and visual observation for all staff to ensure this will not occurred going forward.
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This requirement was not met as evidenced by: A child fell and sustained injuries, the teacher was not observing while occupying by other children and material preparation. This poses an immediately safety & health risk to children in care.
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According to AB 633, all parents of children currently enrolled and any future children being enrolled for the next 12 months must be provided with this report which contains this type A deficiency.
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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: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
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