Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408782
Report Date: 01/12/2017
Date Signed: 01/12/2017 04:13:29 PM

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:KIDDIE ACADEMY OF SAN JOSEFACILITY NUMBER:
434408782
ADMINISTRATOR:MARIE NUNEZFACILITY TYPE:
840
ADDRESS:521 WEST CAPITOL EXPRESSWAYTELEPHONE:
(408) 978-1500
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:21CENSUS: 8DATE:
01/12/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Shefali MalhotraTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Pam Burkett, conducted an unannounced random inspection visit to the facility today. LPA met with Shefali Malhotra, teacher and explained the nature of today's visit. Director, Marie Nunez was leaving when LPA arrived. We spoke briefly. Ravinder, owner was here most of the visit and had to leave at 3:00 PM. LPA explained the nature of today's visit. LPA toured the facility both inside and outside during today's visit. There were 8 children in the school age room with one fully qualified teacher. The facility is in ratio.

LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), and Personal Rights (LIC 613A).

A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded Shefali of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violations within a 12 month period.

LPA reviewed two children's and one staff files during today's visit. Each child's file reviewed contains the Information and Emergency Information form (LIC 700). Staff file contain the required transcripts/verification of experience. Staff first aid and CPR certification is current. Shefali understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips).
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Pam BurkettTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: KIDDIE ACADEMY OF SAN JOSE
FACILITY NUMBER: 434408782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2017
Section Cited
101529.1
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Sign In and Sign Out - All children must be signed in and out every day. One child was not signed out for the past two days.
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A written plan of correction will be submitted by 1/19/17.
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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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Pam BurkettTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2017
LIC809 (FAS) - (06/04)
Page: 3 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: KIDDIE ACADEMY OF SAN JOSE
FACILITY NUMBER: 434408782
VISIT DATE: 01/12/2017
NARRATIVE
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Shefali understands the conditions, limitations, and capacity specifications of the facility license. Shefali understands that children shall be visually supervised at all times. The facility is aware of the required sign in and sign out procedures for school age children. Shefali states that all school age children are picked up by their parent(s)/guardian(s) and no children are allowed to leave the facility on their own. One child was not signed out for the past two days.

LPA observed that the room is clean and safe for all children and staff. Drinking water is readily available for the children in the room and in the outdoor playground. LPA observed solid waste containers with tight-fitting lids in each room. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff bathroom. Shefali states that there are no weapons or firearms on the premises.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. Cleaning supplies are inaccessible to the children and stored in locked cabinets inaccessible to children. LPA discussed IMS with Shefali.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. There is sufficient resilient materials in the outdoor playground area. LPA did not observe any bodies of water during today's visit.

Type B deficiency was cited during this visit.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Pam BurkettTELEPHONE: (408) 334-8546
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2017
LIC809 (FAS) - (06/04)
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