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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408782
Report Date: 07/15/2021
Date Signed: 07/15/2021 02:41:09 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: 14DATE:
07/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marie NunezTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Janette Cruz, conducted an unannounced follow-up case management inspection today to deliver an amended report dated 7/13/21 regarding an Unusual Incident that the facility self-reported to the Department.

An exit interview was conducted with director.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.





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SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021
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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