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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408782
Report Date: 07/13/2021
Date Signed: 07/15/2021 02:43:54 PM

Document Has Been Signed on 07/15/2021 02:43 PM - It Cannot Be Edited

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: 21TOTAL ENROLLED CHILDREN: 0CENSUS: 18DATE:
07/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Marie NunezTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janette Cruz and Licensing Program Manager (LPM) Diana Stephenson, conducted an unannounced case management inspection today in response to an Unusual Incident that the Facility self-reported to the Department. LPA/LPM spoke with Marie Nunez, director, and discussed the Unusual Incident with her.

LPA/LPM conducted interviews and record reviews during today’s inspection.

A Type A deficiency is cited during today’s tele-inspection. See LIC809-D.

LPA discussed the requirements of AB633 to Licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Licensee understands the requirements. Upon receipt, Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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.
Diana Stephenson
Janette Cruz
DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2021
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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Document Has Been Signed on 07/13/2021 04:32 PM - It Cannot Be Edited


Created By: Janette Cruz On 07/13/2021 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2021
Section Cited

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101223 (a) (3) Personal Rights. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as evidenced by:
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Based on observations, interviews and record reviews, it was discovered that S1 yelled at C1 on 7/02/21 in front of staff and children 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.
SUPERVISOR'S NAME:Diana Stephenson
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2021


LIC809 (FAS) - (06/04)
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