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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415820
Report Date: 09/28/2021
Date Signed: 09/29/2021 09:27:18 AM

Document Has Been Signed on 09/29/2021 09:27 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 ALMADEN VALLEYFACILITY NUMBER:
434415820
ADMINISTRATOR:OLIVIA LOPEZFACILITY TYPE:
850
ADDRESS:16607 ALMADEN EXPRESSWAYTELEPHONE:
(408) 752-4803
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY: 142TOTAL ENROLLED CHILDREN: 142CENSUS: DATE:
09/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Olivia LopezTIME COMPLETED:
12:30 PM
NARRATIVE
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On 09/28/2021 at 12:00 PM, Licensing Program Analyst (LPA) Susy Cervantes met with director, Olivia Lopez, and owner, Rick Kowalczyk, for a case management- incident visit. Purpose of today's inspection: address an Unusual Incident that the Facility self reported to Community Care Licensing.

The Unusual Incident occurred on August 26, 2021, center director called to report that a staff had been observed handling a child inappropriately. Facility personnel conducted their own internal investigation. The accused staff was terminated by the Facility on August 26, 2021 as a result of the Facility investigation findings.

Director and owner stated that all staff were coached regarding safe handling of children after the incident.

Type A deficiency cited during today's visit. Appeal rights were provided to director, Olivia Lopez, during today's visit.


A notice of site visit was issued and posted near the facility entrance along with the Type "A" deficiency and both notices must remain posted for 30 consecutive days. The Licensee must provide copies of this report to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility during the next 12 months.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 09/29/2021 09:27 AM - It Cannot Be Edited


Created By: Susy Cervantes On 09/28/2021 at 10:57 AM
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: KIDDIE ACADEMY OF ALMADEN VALLEY
FACILITY NUMBER: 434415820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2021
Section Cited
CCR
101223(a)(3)

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101223(a)(3)- Personal Rights
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature ... This requirement was not met as evidenced by:
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Facility terminated staff immediately and pursued legal accion with police department and CDSS. Director and owner stated training for staff was conducted on 09/21/21. Owner stated staff were individually spoken to after the incident.
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Based on interviews and observations, staff had been observed handling a child inappropriately. This poses an immediate risk to the health and safety of the children in care.
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Director will submit meeting agenda to San Jose Reginal Office by close of business on September 29, 2021.

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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:Mary Segura
LICENSING EVALUATOR NAME:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021


LIC809 (FAS) - (06/04)
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