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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435700718
Report Date: 04/22/2022
Date Signed: 04/22/2022 11:39:43 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2022 and conducted by Evaluator Jonathan Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20220413085559
FACILITY NAME:BUILDING KIDZ PALO ALTOFACILITY NUMBER:
435700718
ADMINISTRATOR:PATEL, VIBHUTIFACILITY TYPE:
850
ADDRESS:415 LAMBERT AVENUETELEPHONE:
(650) 224-2144
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:96CENSUS: 41DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Vibhuti PatelTIME COMPLETED:
11:53 AM
ALLEGATION(S):
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Staff pulled on child's arm resulting in injury.
INVESTIGATION FINDINGS:
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On 4/22/2022, Licensing Program Analyst (LPA) Jonathan Williams arrived to the facility unannounced to conclude investigation into the above allegation. LPA was met by Director, Vibhuti Patel. Present during today's visit were the Director, six fingerprint cleared staff members, and 41 preschool-aged children in care.

During the course of the investigation, LPA interviewed staff members, viewed security camera footage, interviewed pediatrician, and reviewed facility records. Based on review of security camera footage watched by LPA, it was determined that a staff member had pulled on a child's arm, accidentally resulting in a dislocated or "nursemaid's" elbow. The preponderance of evidence standard has been met; therefore, the allegation is deemed SUBSTANTIATED. See LIC809-D for citation assessed.

Exit interview conducted. Appeal Rights provided. Notice of site visit given. Director is advised that LIC9224 must be provided to parents of current children in care and parents of all children subsequently enrolled for a period of 12 months.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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 2
Control Number 52-CC-20220413085559
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: BUILDING KIDZ PALO ALTO
FACILITY NUMBER: 435700718
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2022
Section Cited
CCR
101223(a)(3)
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(a) The licensee shall ensure that each child is accorded the following personal rights... (3) To be free from... infliction of pain...

This requirement was not met as evidenced by:

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Director shall conduct staff training on the proper handling of young children susceptible to "nursemaid's elbow" and distribute UCSF and Mayo Clinic resources provided by LPA to staff for further review. Director shall submit proof of completion to LPA.
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Based on review of security camera footage, a staff member had pulled on a child's arm, accidentally causing a dislocated or "nursemaid's" elbow.
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Failure to correct by the POC due date may result in civil penalty assessment.
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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: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2