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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406756
Report Date: 12/23/2024
Date Signed: 12/23/2024 09:23:39 AM

Document Has Been Signed on 12/23/2024 09:23 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KIDANGO HUBBARD CENTERFACILITY NUMBER:
434406756
ADMINISTRATOR/
DIRECTOR:		JACKELIN SOLORIOFACILITY TYPE:
850
ADDRESS:1680 FOLEY AVENUETELEPHONE:
(408) 353-0559
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 40TOTAL ENROLLED CHILDREN: 42CENSUS: 1DATE:
12/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Jackelin SolorioTIME VISIT/
INSPECTION COMPLETED:
09:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mandeep Kaur, met with Director, Jackelin Solorio and explained the purpose of the investigation: continuation of the Case Management- Incident investigation, that was self reported on 12/11/2024. LPA conducted incident investigation comprising of interviews and records review.

During today's investigation, LPA interviewed Director.

Director stated that incident occurred on December 10, 2024 about 10:30am. Director self-admitted that a child (C1) was left behind in the corridor between Rooms 82 & 83 and Staff (S1) brought the child back to Room 82 after Room 82 door was closed behind.

Director stated that training on active supervision was provided to all staff on December 13, 2024. Copies of training material with staff attendance sheet was provided during today's investigation.,

As a result of this investigation, LPA concludes that a child (C1) was left behind without the supervision of a staff in the corridor. Therefore, one "Type B deficiency is issued today on the attached 809-D.

Exit interview conducted and report was reviewed with Director, Jackelin Solorio and copy of appeal rights was provided.

A NOTICE OF SITE VISIT HAS BEEN GIVEN AND MUST BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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Document Has Been Signed on 12/23/2024 09:23 AM - It Cannot Be Edited


Created By: Mandeep Kaur On 12/23/2024 at 08:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: KIDANGO HUBBARD CENTER
FACILITY NUMBER: 434406756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2025
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision: (a)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, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
This requirement was not met as evidenced by:
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By Plan of correction due date, 01/06/2025, Director will submit the written statement of understanding of Title 22 regulations: responsibility for providing care and supervision and a written plan to make sure of providing care and supervision to the children in care at all times, to the department.
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Based on interviews, a child (C1) was left behind alone in corridor without the supervision of a staff around 10:30AM on 12/10/2024, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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:Belinda Devall
LICENSING EVALUATOR NAME:Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
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