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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416419
Report Date: 12/01/2021
Date Signed: 12/01/2021 03:52:00 PM

Document Has Been Signed on 12/01/2021 03:52 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:BUILDING KIDZ SCHOOLFACILITY NUMBER:
434416419
ADMINISTRATOR:MANALI AMAR DOSHIFACILITY TYPE:
850
ADDRESS:4115 JACKSOL DRIVETELEPHONE:
(408) 559-1003
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 73TOTAL ENROLLED CHILDREN: 57CENSUS: 41DATE:
12/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Manali Doshi and Adela BjelevacTIME COMPLETED:
04:06 PM
NARRATIVE
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Licensing Program Analyst (LPA), James Santos arrived at the facility today to conduct a case management visit. LPA met with Administrator, Manali Doshi and Director, Adela Bjelevac.

The purpose of the case management visit was in regards to an incident that the facility self reported. On 11/30/2021, Administrator sent an Unusual Incident Report to CCL reporting that on 11/29/2021 between 11:30 - 11:45am, a substitute teacher went to the bathroom through the gate but was not aware that the gate did not fully closed. As a result, a child ran out and was reported found in the courtyard by a school district staff who brought the child back to the teacher in the playground area. The courtyard is located within the gated school district campus. The incident occurred during the children's playground time. The child was doing ok after the incident.

There were 3 other teachers and another substitute teacher were present during the playground time. One teacher was helping few children to the bathroom and the other teachers were with the other children in the playground. Per administrator, they were well in ratio that day: 29 children with 3 fully qualified teachers, 1 assistant and 1 aide.

Per administrator, she already spoke with the child's parents about the incident. Also, the administrator spoke to the teachers individually and reviewed safety guidelines.

As a result of the incident, a citation was issued and civil penalty assessed.

Appeal rights printed and reviewed with Administrator.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
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 12/01/2021 03:52 PM - It Cannot Be Edited


Created By: James G Santos On 12/01/2021 at 03:27 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: BUILDING KIDZ SCHOOL
FACILITY NUMBER: 434416419

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/02/2021
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision:
The licensee shall provide care and supervision as necessary to meet the children's needs. 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.
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Administrator agreed to write a supervision and safety plan and discuss with staff to ensure that all children will be visually supervised and accounted for at all times, including transition. POC to be submmited to LPA by due date, 12/2/2021 .
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This requirement was not met as evidenced by: Based on the report, the child ran out to the courtyard without staff visual observation leaving the child unsupervised. This poses an immediate threat to health and safety of children in care.
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*Civil penalty assessed - Immediate $500 Violation.

According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months and copy of signed acknowledgement form must be kept in each child's file.

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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:Joel Segura
LICENSING EVALUATOR NAME:James G Santos
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021


LIC809 (FAS) - (06/04)
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