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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000489
Report Date: 07/02/2024
Date Signed: 07/02/2024 03:29:14 PM

Document Has Been Signed on 07/02/2024 03:29 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:IHSD, INC-SERRAMONTE HEAD START CENTERFACILITY NUMBER:
414000489
ADMINISTRATOR/
DIRECTOR:		ZOHREH KHOSHENEVISIANFACILITY TYPE:
850
ADDRESS:699 SERRAMONTE BLVD.TELEPHONE:
(650) 992-6027
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 40TOTAL ENROLLED CHILDREN: 39CENSUS: 32DATE:
07/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Zoreh Khoshenevisian and Leanne HayTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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T1=Teacher 1; T2= Teacher 2; T3=Teacher 3; C1= Child 1.

On July 2, 2024 at approximately 2:15pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, case management visit to IHSD Serramonte Head Start. LPA met with director, Zoreh Khoshenevisian, and children services manager, Leanne Hay, and explained the purpose of the visit.

Present during LPA's visit included 32 preschool children. Program operates in Classroom A and Classroom B.

The case management visit is in regards to an unusual incident that occurred on June 24, 2024. Children services manager self-reported incident to department.

On June 24, 2024 at approximately 10:45am, T1, T2 and T3 were present in the enclosed, outdoor play area with 16 preschool children. Per director, children were transitioning from outdoor area back to Classroom A. Transition protocol includes children lining up, staff counting and communicating the number of children present and walking back to classroom in two separate groups of 8 children.

While returning to Classroom A, C1 was left in the play area without staff supervision. C1 was found by teaching staff from Classroom B and returned to Classroom A, without any injuries. Per children services manager, time from C1 was left in the outdoor area, found in the outdoor area and returned to Classroom A was approximately 4 minutes. C1's authorized representative was informed of incident on the same date. C1 has returned to facility as per their normal. All authorized representatives' of all enrolled children have also been informed of incident.
(Continue Report on Page 2...)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: IHSD, INC-SERRAMONTE HEAD START CENTER
FACILITY NUMBER: 414000489
VISIT DATE: 07/02/2024
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(Continued, Page 2...)
On June 24, 2024, children services manager held a staff meeting with T1, T2, and T3, reinforcing the importance of supervision and additional transition protocols. Per director, staff are now to count children with a name to face procedure, documenting the children who are present. Per children services manager, new transition protocol has been implemented agency wide. Since incident, T1, T2, and T3 meet with director and/or children services manager daily. Proof of individual meetings have been provided to LPA during case management visit. Staff are also provided option of mental health counseling.
Based on record review, interview and children services manager self-reporting, a child was left unattended and without staff supervision during operating hours. Facility is cited a Type B citation for lack of supervision. Please refer to 809D for more information.

A notice of site visit was provided and must remain posted for 30 days. Appeal rights were provided to director.

Exit interview conducted and report was reviewed with director, Zoreh Khoshenevisian and children services manager, Leanne Hay.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
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Document Has Been Signed on 07/02/2024 03:29 PM - It Cannot Be Edited


Created By: Catrina Quimbo On 07/02/2024 at 03:02 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: IHSD, INC-SERRAMONTE HEAD START CENTER
FACILITY NUMBER: 414000489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2024
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a)(1) No child(ren) shall be left without the supervision of a teacher at any time.
This requirement was not met as evidenced by:
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C1's family was informed of incident on same date. Children services manager conducted a manadatory staff meeting 6/24/2024. Additional transition protocol has been implemented agency wide, which includes couting children by name to face and documenting the children present.
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Based on record review, interview and children services manager self reporting, C1 was left unattended on the playground and unsupervised by staff.
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Proof of staff meeting was provided to LPA during visit. Staff continue to have training with agency, reminding importance of a child's health and safety. Deficiency cleared during visit.

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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:Marie Rodriguez
LICENSING EVALUATOR NAME:Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
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