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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434417051
Report Date: 02/22/2024
Date Signed: 02/23/2024 03:10:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 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
02/15/2024 and conducted by Evaluator Sheena Chin
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240215153211
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: 51DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cheyenne BohnTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not ensure drinking fountain was working properly
INVESTIGATION FINDINGS:
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On 2/22/24 Licensing Program Analyst (LPA), Sheena Chin conducted an unannounced 10-day complaint investigation at the facility. LPA met with the director, Cheyenne Bohn and explained the purpose of the inspection. During today's investigation, LPA observed children’s activities, reviewed records, and interviewed staff. LPA observed that the drinking water fountain in the pre-K playground was not maintained in good condition and was not working properly. The drinking fountain was not able to drain the water out and the water was retained in the fountain.

Based on the observations, the preponderance of evidence standard has been met, therefore the allegation of “Staff did not ensure drinking fountain was working properly.“ is found to be SUBSTANTIATED.

continue to LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 4
Control Number 07-CC-20240215153211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KINDERWOOD PRESCHOOL
FACILITY NUMBER: 434417051
VISIT DATE: 02/22/2024
NARRATIVE
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A deficiency is being cited on LIC9099D.

Exit interview was conducted, where this report, the citation, plan of correction, and appeal rights were reviewed and discussed with the director , Cheyenne Bohn.

Notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 07-CC-20240215153211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KINDERWOOD PRESCHOOL
FACILITY NUMBER: 434417051
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/07/2024
Section Cited
CCR
101239(n)
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101239 Fixtures, Furniture, Equipment and Supplies (n) Furniture and equipment shall be maintained in good condition...

This requirement was not met as evidenced by :
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The director stated that the equipment has arrived and the handyman will install the new drinking fountain on 2/24/24. The director stated that a photo of the new drinking fountain installed will send to LPA,
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Based on observation the facility did not comply with the section cited above. The drinking fountain was not mained in good condition, 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.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4