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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415820
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:19:37 PM


Document Has Been Signed on 11/09/2023 03:19 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:KIDDIE ACADEMY OF ALMADEN VALLEYFACILITY NUMBER:
434415820
ADMINISTRATOR:OLIVIA LOPEZFACILITY TYPE:
850
ADDRESS:16607 ALMADEN EXPRESSWAYTELEPHONE:
(408) 752-4803
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY:142CENSUS: 117DATE:
11/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sarah Laub & Rick KowalczykTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janette Cruz conducted an unannounced case management during another visit and met with Sarah Laub, Interim Director and Rick Kowalczyk, Licensee. LPA reviewed staff and a child's file during today's inspection.

A deficiency was cited, appeal rights were given to Licensee, See (809-D). Exit interview conducted and report was reviewed with the Sarah Laub, Interim Director and Rick Kowalczyk, Licensee,

A Notice of Site Visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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 3


Document Has Been Signed on 11/09/2023 03:19 PM - 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 ALMADEN VALLEY
FACILITY NUMBER: 434415820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2023
Section Cited
HSC
1596.8662(b)(1)

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1596.8662(b) (1)   On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement was not met as evidenced by:
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Licensee will submit Mandated Reporter training for staff S4 and S12 by POC due date.
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Based on record review, Licensee did not comply with the section cited above. Licensee did not obtain Mandated Reporter Training certification for staff S4 and S12
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Type B
11/23/2023
Section Cited
CCR101216(g)(2)(A)

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101216 Personnel Requirements
(g) All personnel, including the licensee, administrator and volunteers, shall be in good health and shall be physically and mentally capable of performing assigned tasks.(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:
(A) The person's physical qualifications to perform the duties to be assigned.This requirement was not met as evidenced by:
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Licensee will submit LIC503 Health Screening reports for staff S1 and S3
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Based on record review, Licensee did not comply with the section cited above. Licensee did not obtain LIC503Health Screening reports for staff S1 and S3 which posed 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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/09/2023 03:19 PM - 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 ALMADEN VALLEY
FACILITY NUMBER: 434415820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2023
Section Cited
HSC
1596.7995(a)(1)

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1596.7995 Employees or volunteers at day care center; immunization requirements; records; exemptions (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement was not met as evidenced by:
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Licensee will submit proof of immunization for pertussis for S1 for staff and measles immunization for S4.
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Based on record review, Licensee did not comply with the section cited above. Licensee did not obtain immunizations required prior to employment for staff S1 and S4 which posed 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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
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