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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412171
Report Date: 03/29/2023
Date Signed: 03/29/2023 11:40:54 AM


Document Has Been Signed on 03/29/2023 11:40 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:KIDDIE ACADEMY OF CUPERTINOFACILITY NUMBER:
434412171
ADMINISTRATOR:XIONG, ANGELAFACILITY TYPE:
850
ADDRESS:19875 STEVENS CREEK BLVD.TELEPHONE:
(408) 517-0454
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:119CENSUS: 61DATE:
03/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Angela XiongTIME COMPLETED:
11:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico made a Case Management Inspection in response to an unusual incident that was self-reported by the facility to Licensing on March 27, 2023. LPA met with Site Director, Angela Xiong, and explained the nature of today's inspection. LPA toured the facility, interviewed staff, reviewed files, and obtained documents.

Based on available evidence and interviews, it was determined that on March 23, 2023, the children in Room 4 and Room 7 were in the playground. Staff (S-1) brought three children including C-1 from the playground to use the bathroom in Room 7. At around 4 PM, Staff (S-2) found C-1 alone in Room 7. S-2 brought C-1 to the playground and handed the child to S-3. Site Director was notified by S-3 about the incident. Site Director immediately contacted C-1's parent to notify them of the incident. Site Director had one on one training with staff regarding supervision , name to face including headcounting, and restroom plan for outside after the incident. S-1 was terminated on March 24, 2023.

Exit interview was conducted and report was reviewed with Site Director, Angela Xiong.

As a result of this inspection, deficiency was cited on the following page:

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
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 03/29/2023 11:40 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: KIDDIE ACADEMY OF CUPERTINO
FACILITY NUMBER: 434412171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2023
Section Cited

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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.
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Site Director conducted one on one training with all staff regarding supervision, name to face including headcounting, and restroom plan for outside after the incident. S-1 was terminated on 03/24/23.

Deficiency corrected.
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This requirement was not met as evidenced by: A child (C-1) was found by a staff member (S-2) unattended in Room 7. This poses an immediate risk to the health, safety, and personal rights of children in care.

An immediate civil penalty of $500 was assessed.
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Upon receipt, licensee shall post and provide copies of this licensing report 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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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