<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412429
Report Date: 06/06/2023
Date Signed: 06/06/2023 02:59:39 PM

Document Has Been Signed on 06/06/2023 02:59 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KIDANGO MEADOWFAIRFACILITY NUMBER:
434412429
ADMINISTRATOR:YADIRA RIOSFACILITY TYPE:
850
ADDRESS:2696 SOUTH KING ROADTELEPHONE:
(408) 353-0680
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 18DATE:
06/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Vera KindleTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Harsimran Kaur, conducted an unannounced Case Management Inspection in response to an unusual incident that the facility self reported to Community Care Licensing (CCL). LPA met with the Head Teacher,Vera Kindle, and explained the nature of today's inspection.

This visit was made to inquire about an unusual incident that occurred on May 16, 2023.

During today's visit LPA Kaur toured the facility, interviewed staff, Based on staff interviews, as well as the self reported incident report. On May 16,2023, child was left behind in the play yard for approximately 4 to 5 minutes while they transitioned into classroom from play yard.

Exit interview conducted, and a copy of this report was provided and reviewed with the Head Teacher, Vera Kindle.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):



"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS. LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH APPLICANT/PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Harsimran Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/06/2023 02:59 PM - It Cannot Be Edited


Created By: Harsimran Kaur On 06/06/2023 at 12:50 PM
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 MEADOWFAIR
FACILITY NUMBER: 434412429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2023
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
101229 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:
1
2
3
4
5
6
7
Director to conduct a training for staff and provide documentation of training.
8
9
10
11
12
13
14
Based off of report sent in by facility and interviews conducted it was found that child was left alone in playyard for 4 to 5 minutes .
This poses an imediate health and safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Diana Stephenson
LICENSING EVALUATOR NAME:Harsimran Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2