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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002689
Report Date: 09/20/2024
Date Signed: 09/20/2024 11:10:02 AM

Document Has Been Signed on 09/20/2024 11:10 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:MSD GEOKIDS (PRESCHOOL)FACILITY NUMBER:
414002689
ADMINISTRATOR/
DIRECTOR:		BOURNE, KIMFACILITY TYPE:
850
ADDRESS:345 MIDDLEFIELD RD., M/S 204TELEPHONE:
(650) 329-4236
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 62TOTAL ENROLLED CHILDREN: 58CENSUS: 36DATE:
09/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Chae MarshallTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On September 20th, 2024, at approximately 8:30am Licensing Program Analyst (LPA) Kassandra Medrano was granted entry by Violet Balverde, Associate director, the purpose of the visit was explained. Later during inspection at approximately 10am, met with Site Director, Chae Marshall. The purpose of the inspection was to discuss an unusual incident that occurred on September 12th, 2024, which was reported to the regional office by the facility on September 13th, 2024. LPA toured through facility with Violet, and during inspection all staff that were found in the preschool classroom were associated to the facility and fingerprint cleared.

On the day mentioned above, while transitioning from nap/snack to conduct “JAMaRoo Kids” in the yard which is a music program that takes place every Thursday at 4pm. S1 took 15 children outside for the class and conducted a head count. While S2 stayed at door with 3 children who were toileting, staff then took 2 children outside. Approximately 10 minutes later, the staff were informed by a parent had arrived to pick up their child and found C1 playing inside classroom. Based on investigation conducted by the facility it was found that C1 was hidden behind the mat cubby door, and remained at the light table when head counts were being conducted. Based on documents received and interviews conducted, the incident resulted in absence of supervision because the child was left without visual supervision of a teacher.

The center was advised of requirements of type a citation. The facility must provide a copy of the Evaluation Report and the Type “A” Deficiency cited to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. As well as a signed and dated LIC 9224 shall be maintained in all Children's files.



This report and appeal rights were provided and exit interview was conducted with the Site Director, Chae Marshall. Notice of Site Visit and Type A Citation shall remain posted for 30 days.

California Code of Regulations, Title 22 Type A deficiencies are being cited on the following page(s):
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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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Document Has Been Signed on 09/20/2024 11:10 AM - It Cannot Be Edited


Created By: Kassandra Medrano On 09/20/2024 at 09:27 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: MSD GEOKIDS (PRESCHOOL)
FACILITY NUMBER: 414002689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
1010229(a)(1)

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1) No child shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
This requirement was not met as evidenced by:
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Director stated that they have conducted an all staff training on ratios and tracking. Director to write up what was covered in the training and send documentation to LPA.
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Based on documents recieved and interviews conducted C1 was left in a classroom without supervision. This posed an immediate health and safety risk.
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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:Ali Zebila
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
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