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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410518747
Report Date: 06/14/2023
Date Signed: 06/14/2023 01:41:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2023 and conducted by Evaluator Leslit Tapia-Mandujano
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20230418082937
FACILITY NAME:RCSD CHILD DEV SERVICES-HOOVER STATE PRESCHOOLFACILITY NUMBER:
410518747
ADMINISTRATOR:PENA, ROXANAFACILITY TYPE:
850
ADDRESS:701 CHARTER ST, PORT 1,2,3,& 4TELEPHONE:
(650) 482-2407
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY:105CENSUS: 56DATE:
06/14/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Site Supervisor, Roxana PenaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff are not following admission agreement
INVESTIGATION FINDINGS:
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On June 14th at approximately 11:30am, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced, complaint investigation and met with Site Supervisor, Roxana Pena regarding above allegations and explained the purpose of the visit. LPA and Site Supervisor toured the facility for health and safety hazards and LPA conducted staff interviews.

Complaint was received by the Department on 04/18/23. Present in the facility are Site Supervisor and 10 teachers caring for 56 preschool age children. All adults working or living in the facility have fingerprint clearance and are associated through the School District.

During the Investigation, LPA conducted file review, interviews with staff, parents, and received pertinent documentation. During the course of the investigation, LPA determined that staff are not following admission agreement in regards to the hours of operation set by the admission agreement.

Based on interviews, and record review which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1, are being cited. Please refer to 9099D for more information.

Upon receipt of this report, Facility shall post the Notice of Site Visit. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain postings as required, will result in an immediate $100 civil penalty. This report is public and can be reviewed.

After today’s visit, an exit interview was conducted, report was reviewed and copy was provided to Site Supervisor, Roxana Pena.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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 2
Control Number 05-CC-20230418082937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: RCSD CHILD DEV SERVICES-HOOVER STATE PRESCHOOL
FACILITY NUMBER: 410518747
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
101219(f)
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101219(f): Admission Agreements: "The licensee shall comply with all terms and conditions set forth in the admission agreement."

This requirement is not met by:
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LPA and Site Supervisor had a conversation about following Admission Agreement regulation and ensuring that the Admission Agreement polices are followed as stated.

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Based on interviews and record review, the facility did not comply with the section cited above as staff are not following the operational hours set forth by the admission agreement, which poses a potential health, safety or personal rights risk to persons in care.
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Site Supervisor will have a meeting or talk with all staff to ensure that no staff is asking parents to pick up before the operational hours. Facility will provide proof of completion by having all staff sign a statement understanding the admission agreements by 6/23/23.
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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: Ali Zebila
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
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