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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415705
Report Date: 04/07/2023
Date Signed: 04/07/2023 01:54:00 PM

Document Has Been Signed on 04/07/2023 01:54 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 FOXDALEFACILITY NUMBER:
434415705
ADMINISTRATOR:THAO NGUYENFACILITY TYPE:
850
ADDRESS:1250 FOXDALE LOOPTELEPHONE:
(408) 290-7666
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 16DATE:
04/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Thao NguyenTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Harsimran Kaur, conducted an unannounced case management inspection in response to a completed lead testing. which resulted in one action level exceedances within the facility of 11 ppb. LPA met with the Director, and explained Thao Nguyen the nature of today's inspection.

Prior to today’s inspection, Community Care Licensing received notification of the lead exceedances by the water program. Preceding the arrival of Kaur, the fountain that have been found in exceedance have been taped off and are not being used.

The water sample conducted by Alpha laboraties on 10/14//22, indicated the following:
1) Water bubbler and sink named "I" located in restroom has Lead Action Level Exceedance value of 11 ppb.


LPA has the obtained documents during today’s inspection Director.
1.Self-Certification (LIC9275)
2.Sampling Checklist Form (LIC9276)
3.Facility Sketch LIC 999 (fully labeled with locations of all water outlets)
4. Full lead report from water program

Type B deficiency was cited, exit interview conducted, and a copy of this report was given and reviewed with the Facility Representative, Thao Nguyen. Appeal rights were reviewed and provided.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Harsimran Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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 04/07/2023 01:54 PM - It Cannot Be Edited


Created By: Harsimran Kaur On 04/07/2023 at 12:35 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 FOXDALE
FACILITY NUMBER: 434415705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives section 101700.3 (b)(1),
a result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidenced by:
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Director, Thao Nguyen stated that they will remediate the exceedances and contact Alpha to retest. Director stated she will send documentation of remidation as well as retesting.
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This exceedance levels found in “I” bubbler and sink was 11 ppb. This poses a potential risk to the Health, Safety, or Personal Rights of children 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:Diana Stephenson
LICENSING EVALUATOR NAME:Harsimran Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
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