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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002884
Report Date: 10/29/2024
Date Signed: 10/29/2024 04:09:33 PM

Document Has Been Signed on 10/29/2024 04:09 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:PFS-BAYSHORE 87TH STREET CDC (PS)FACILITY NUMBER:
414002884
ADMINISTRATOR/
DIRECTOR:		MARILYN LAZANAFACILITY TYPE:
850
ADDRESS:377 - 87TH STREETTELEPHONE:
(415) 330-1715
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 32TOTAL ENROLLED CHILDREN: 31CENSUS: 25DATE:
10/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Marilyn LazanaTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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S1= Staff 1; S2= Staff 2; S3= Staff 3; C1= Child 1

On October 29, 2024 at approximately 1:15pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, case management visit in regards to an incident that was self-reported to department October 16, 2024. LPA met with site supervisor, Marilyn Lazana, and explained the purpose of the visit. Present during LPA's visit included 25 preschool children and 6 teaching staff.

On October 15, 2024 at approximately 4:15pm, all enrolled children and two teaching staff were present in the outdoor area. S1, S2, and C1 were present in preschool classroom #2. C1 utilized children's restroom that is located and shared between preschool classroom #1 and preschool classroom #2.

As C1 was using children's restroom, S3 also entered the children's restroom. S3 used the children's restroom simultaneously while C1 used the children's restroom. On October 16, 2024, teaching staff on site reported incident to Peninsula Family Service program director. Program director conducted an internal investigation. On October 16, 2024, S3 was terminated from facility. C1's authorized representative was informed of incident on the same date. On October 18, 2024 an informal staff meeting was held.

During today's visit, LPA conducted staff interviews and inspected children's restroom. LPA observed 4 toilets in children's restroom, aligned right next to each other. LPA did not observe any privacy between children's toilets. LPA observed doors to children's restroom to be half-partition doors to maintain supervision.
LPA determined C1's personal rights were violated on October 15, 2024 when S3 utilized children's restroom while C1 utilized children's restroom. Facility is being cited under Title 22, Division 12, Chapter 1. See 809D for details. A hard copy of today's report was provided to site supervisor as well as appeal rights.

A notice of site visit was given and must remain posted.

Exit interview conducted and report was reviewed with site supervisor, Marilyn Lazana.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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 10/29/2024 04:09 PM - It Cannot Be Edited


Created By: Catrina Quimbo On 10/29/2024 at 03:36 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: PFS-BAYSHORE 87TH STREET CDC (PS)
FACILITY NUMBER: 414002884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
101223(a)(2)

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101223 Personal Rights (a) ...each child is...(2) To be accorded safe, healthful and comfortable accommodations...to meet his/her needs.

This requirement was not met as evidenced by:
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Facility self reported incident. S3 was terminated from program and facility. An informal staff meeting was held after incident took place. A formal, all staff meeting will occur, developing an action plan to reinforce children's privacy while in the restroom and children's personal rights.
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Based on observation, interview and record review, S3 simultaneously used the children's restroom while C1 used the children's restroom. LPA observed children's restroom to have no privacy between children's toilets. This posed a potential health, safety or personal rights risk to children in care.
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Written action plan with teaching staffs' signatures will be submitted to LPA by POC due date.

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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: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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