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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415211
Report Date: 12/04/2023
Date Signed: 12/04/2023 12:01:06 PM

Document Has Been Signed on 12/04/2023 12:01 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KIDANGO ARBUCKLEFACILITY NUMBER:
434415211
ADMINISTRATOR:VANESSA PAIZFACILITY TYPE:
830
ADDRESS:1910 CINDERELLA LN, RM 165&166TELEPHONE:
(408) 905-8985
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 22DATE:
12/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sandra Valencia-ChavezTIME COMPLETED:
12:00 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
LPA Sheena Chin conducted an unannounced Case Management - Incident Visit to the facility in response to an incident that occurred on 11/17/2023. LPA met with the assistant center director, Sandra Valencia-Chavez and explained the purpose of the visit.

The facility reported that the child, C1, was left behind about 1 minute during the transitioning from playground to the classroom. The preschool teacher brought the child back to the classroom.

Staff interviewed from room 166 stated that all 8 kids on 11/17/2023 were back in the classroom from the grass area but the child, C1, opened the door and ran outside after washing hands. The teacher, T1, stated that she noticed the child left the room and had the aid, A1, take the child, C1, back in the classroom. When the aid, A1, was about to go outside, the child, C1 was brought back by the other aid, A2 from room 77. The teacher, T2, from room 77 stated that she was in the playground with 15 preschool kids and saw the child, C1, stood outside of the room 166. T2 stated that she asked the aid, A2 to take the child, C1, back to the room 166. LPA advised the assistant center direct to update the incident report on 11/17/2023 and to have teacher lock the handle when kids are in the room.

Exit interview was conducted, and the report was reviewed with the assistant center director, Sandra Valencia-Chavez.
A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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 1