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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002299
Report Date: 08/22/2024
Date Signed: 08/22/2024 11:31:06 AM

Document Has Been Signed on 08/22/2024 11:31 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CITY OF PACIFICA-FAIRMONT STATE PRESCHOOLFACILITY NUMBER:
414002299
ADMINISTRATOR/
DIRECTOR:		LILLIAN PAULSENFACILITY TYPE:
850
ADDRESS:649 PARKVIEW CIRCLETELEPHONE:
(650) 738-7381
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 13DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Lillian PaulsenTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 8/22/2024, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced case management visit to the City of Pacifica-Fairmont State Preschool. The purpose of the visit was to follow up with a self reported incident involving a child and a staff member. LPA met with director, Lillian Paulsen, and explained the purpose of the visit. Facility is a single floor building. All staff working in the facility have on file finger print clearance.

Present during inspection included 13 enrolled children, director, one teacher, and one Teacher's aide. Preschool program currently operates Monday through Friday 7:00 AM to 6:00 PM. Facility is operating within its capacity and in accordance with the required ratio of staff to children.


The director stated that incident was reported to her 8/14/2024. Per director, Lillian Paulsen, since the incident the local police department has been notified, and Substitute teacher has had her assignment at facility stopped through the Child Care Careers Substitute Agency the teacher worked for. Child involved in incident is still enrolled and attending Preschool Program. Per director, parent has requested additional supervision.

No deficiencies were issued today during LPA's visit.

A copy of today’s report was given to the director, Lillian Paulsen.

A Notice of Site Visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the lead teacher, Lillian Paulsen.

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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