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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417051
Report Date: 06/29/2023
Date Signed: 06/29/2023 01:15:24 PM

Document Has Been Signed on 06/29/2023 01:15 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:KINDERWOOD PRESCHOOLFACILITY NUMBER:
434417051
ADMINISTRATOR:CHEYENNE BOHNFACILITY TYPE:
850
ADDRESS:5560 ENTRADA CEDROSTELEPHONE:
(408) 839-5669
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 69TOTAL ENROLLED CHILDREN: 73CENSUS: 59DATE:
06/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Cheyenne BohnTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janette Cruz, met with Cheyenne Bohn, Preschool Director for an unannounced case management inspection while conducting a follow-up complaint inspection. During today's inspection LPA observed that staff who floats in both preschool and infant program (434417052) classroom, staff S1, did not have criminal record clearance on file.

A deficiency was cited with civil penalty, appeal rights also given. See (809-D). Exit interview was conducted with Cheyenne Bohn, Director .

A Notice of Site Visit was issued and must be posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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 06/29/2023 01:15 PM - It Cannot Be Edited


Created By: Janette Cruz On 06/29/2023 at 12:22 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: KINDERWOOD PRESCHOOL
FACILITY NUMBER: 434417051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2023
Section Cited
CCR
101170(e)(1)

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Criminal Record Clearance) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by:
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Licensee removed from the facility today. Civil penalty of $500 assessed today (see LIC 421BG). 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 per the AB633 requirements.
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Based on observation, record reviews and interviews, Licensee did not comply with section cited above. S1 who was providing care to children enrolled did not obtain criminal record and child abuse index clearances prior to working in the facility. This poses an immediate threat to health and safety of children in care.
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The Licensee will submit a written statement to the Department by 06/30/23 indicating that they understand that all adult(s) must obtain the required criminal record and child abuse index clearances prior to working or residing in the home.

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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:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


LIC809 (FAS) - (06/04)
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