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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213001939
Report Date: 10/02/2023
Date Signed: 10/02/2023 11:28:53 AM

Document Has Been Signed on 10/02/2023 11:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:C.A.M. (CFS) HAMILTON (PS)FACILITY NUMBER:
213001939
ADMINISTRATOR:LOMBARDI KELSEYFACILITY TYPE:
850
ADDRESS:5520 NAVE DRIVETELEPHONE:
(415) 883-3791
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 80TOTAL ENROLLED CHILDREN: 80CENSUS: 34DATE:
10/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Alida LeonTIME COMPLETED:
11:50 AM
NARRATIVE
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On October 2, 2023, Licensing Program Analysts (LPAs) Garcia and Tse made an unannounced case management visit to the child day care facility listed above and met with Site Supervisor, Alida Leon. Purpose of the visit was explained to the director. The case management visit is from a self reported incident that occurred on 9/19/2023. Unusual incident report was initially reported under the school age license, 210111538. The facility had 34 children and 12 teachers in total on site.

The day of the incident, September 19, 2023, there were 10 students and 4 teachers in the classroom. The program mentor coach, Sheryl Wesley, visited the classroom to check if the class needed support. As she was walking in to ask the teacher, there were no children outside playing. After approximately one minute of conversation with the teacher (Lori), she walked out of the classroom and noticed that there were two students in the play structure. Per Alida, when she talked to the teachers about the incident, one of the teachers went out of the classroom to use the restroom but the teacher did not hear where she was going and the teacher inside the classroom sent the two children outside after applying sunscreen on them. The two teachers had miscommunicated with each other, unknowingly sending the students outside without an adult present.

LPA Garcia interviewed the staff members from room 8 and the child regarding the incident. Based on the interviews and documents obtained and conducted by LPAs, there is lack of active supervision due to the nature of the incident.

Type B Violation 101229 Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the children's needs.

See 2nd Page for 809D Deficiency page

A copy of this report was given to the Licensee and a site visit notification must be posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview was conducted and report was reviewed with Site Supervisor, Alida Leon.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2023
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 10/02/2023 11:28 AM - It Cannot Be Edited


Created By: Nathan Garcia On 10/02/2023 at 10:58 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: C.A.M. (CFS) HAMILTON (PS)
FACILITY NUMBER: 213001939

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2023
Section Cited
CCR
101229(a)

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101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.

This requirement is not met as evidenced by:
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Facility has implemented supervision training on 9/21/2023. Site Director submitted training verification signed by all Room 8 staff. Facility has in-service training every month.
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Children were sent out to play without supervision from teachers. Teachers did not communicate properly regarding who was available to supervise children which poses a potential health and safety risk to children in care.
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Training verification received during visit, deficiency will be cleared on the same day.

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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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023


LIC809 (FAS) - (06/04)
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