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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434408782
Report Date: 10/18/2023
Date Signed: 10/18/2023 02:37:33 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
05/31/2023 and conducted by Evaluator Melvin S Matos
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230531083712
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: 0DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marie NunezTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not report injury to child's authorized representative in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mel Matos conducted an unannounced follow up complaint investigation and met with Marie Nunez, Director. Purpose of today's investigation: deliver investigation findings.
The investigation was conducted by Investigator Rhonda Austin. Based on interviews, observations, record reviews, and evidence gathered during the investigation process, the Department concludes that Facility did not report a child's injury to the child's authorized representative in a timely manner on May 30, 2023. The above allegation is thus found to be SUBSTANTIATED, meaning the allegation is valid because the preponderance of the evidence standard has been met.

A "Type B" deficiency is being cited on the attached LIC 9099-D. Exit interview conducted and report was reviewed with Director, Marie Nunez. Appeal rights were also provided to Marie prior to conclusion of today's inspection. Notice of site visit was issued and must remain posted for 30 days
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
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-20230531083712
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: KIDDIE ACADEMY OF SAN JOSE
FACILITY NUMBER: 434408782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
101226(a)
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Health-Related Services: The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch. The licensee shall obtain specific instructions from the authorized representative regarding action to be taken
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Maria Nunez, director, agreed to submit a written Plan of Correction (POC) listing the Facility protocol for contacting a child's authorized representative whenever a child sustains an injury more serious
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This requirement was not met as evidenced by: Facility did not report a child's injury to the child's authorized representative in a timely manner on May 30, 2023. This presents a potential risk to the health, safety, or personal rights of children in care.
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than a minor cut or scratch.

Plan of Correction is due by Friday October 27, 2023.
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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: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
05/31/2023 and conducted by Evaluator Melvin S Matos
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230531083712

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: 0DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marie NunezTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Day care child sustained a fracture while in care
Outdoor activity space is not maintained in a safe condition
Staff refused to provide day care children with a snack
Staff did not comply with terms of admission agreement
Staff do not provide safe transportation to children in care
Staff yell at day care children
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mel Matos conducted an unannounced follow-up complaint investigation and met with Marie Nunez, Director. Purpose of today's follow up complaint investigation: deliver investigation findings. The investigation of the complaint allegations listed above was conducted by Investigator Rhonda Austin. Based on interviews, observations, record reviews, and evidence gathered during the investigation process, it is concluded that although the allegations noted on this complaint may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. The allegations are thus UNSUBSTANTIATED.

Exit interview conducted and report was reviewed with the Director, Marie Nunez. No deficiencies issued. A notice of site visit was given and must remain posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3