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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434417051
Report Date: 02/16/2024
Date Signed: 02/16/2024 04:00:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2024 and conducted by Evaluator Elizabeth Larios
COMPLAINT CONTROL NUMBER: 07-CC-20240209092443
FACILITY NAME:KINDERWOOD PRESCHOOLFACILITY NUMBER:
434417051
ADMINISTRATOR:CHEYENNE BOHNFACILITY TYPE:
850
ADDRESS:5560 ENTRADA CEDROSTELEPHONE:
(408) 839-5669
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:69CENSUS: 59DATE:
02/16/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Cheyenne BohnTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility did not provide a 30-day notice regarding rate change
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Larios conducted an unannouced initial complaint visit investigation at the facility today and met with Director, Cheyenne Bohn and explained the purpose of today's visit.

Based on interviews conducted and infromation obtained the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Type B deficiency was cited on the attached LIC 9099-D.

Exit interview was conducted, where this report was reviewed and discussed with Cheyenne Bohn. A copy of this report was also provided. Appeal rights were given.

====CONTINUE ON LIC 9099-C====
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 07-CC-20240209092443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KINDERWOOD PRESCHOOL
FACILITY NUMBER: 434417051
VISIT DATE: 02/16/2024
NARRATIVE
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A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 07-CC-20240209092443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KINDERWOOD PRESCHOOL
FACILITY NUMBER: 434417051
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
CCR
101219(b)(4)
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101219 Admission Agreements
(b) Admission agreements shall specify the following:(4) Modification conditions, including the requirement that the child's authorized representative be given at least 30-calendar-days prior written notice of any basic rate change. This requirement was not met as evidenced by:
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Licensee shall provide parents with a 30 day written notice of any basic rate change and submit a copy to CCL by POC date 02/23/2024.
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Based on infromation obtained Director sent out a notice of increase child monthly rates to parents on February 8, 2024 effective March 4, 2024. Director failed to give a required 30 day written notice. This poses a potential risk to the health and safety 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.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3