<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004812
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:19:34 PM

Document Has Been Signed on 10/20/2023 03:19 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:PRIMARY SCHOOL, THEFACILITY NUMBER:
414004812
ADMINISTRATOR:EASTER, KYNDALFACILITY TYPE:
850
ADDRESS:2086 CLARKE AVENUETELEPHONE:
(650) 396-2779
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 98TOTAL ENROLLED CHILDREN: 92CENSUS: 73DATE:
10/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:ECE Dean, Tajmah, Director of Operations and Integration, Nathalie Carvajal, and Dean of Operations, Reyna NietoTIME COMPLETED:
03:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On October 20th, 2023 at approximately 1:45pm, Licensing Program Analyst, (LPA) Tapia-Mandujano arrived at the facility for a Case Management-Incident inspection in concurrent with other inspections. LPA met with ECE Dean, Tajmah Martin, Director of Operations and Integration, Nathalie Carvajal, and Dean of Operations, Reyna Nieto. The purpose of today's inspection was explained. Inspection is for a response to an Unusual Incident Report that was called in On October 5th, 2023 and received by the department on October 6th, 2023.

Facility operates in Classrooms #3,4,5,6,7, and 12. Present in the facility are 12 staff supervising 73 preschool age children. Facility is operating within capacity limits. All adults in the facility are fingerprint cleared and associated. LPA inspected classrooms for Health and Safety Hazards.

The facility self-reported an incident that occured on October 4th, 2023. The incident involved lack of supervision that resulted in a child being left unsupervised while transitioning from outdoor play yard into the classroom. Per the report, the child was left alone in the outdoor play yard for approximately 2 minutes without direct supervision. Child was found by a non ECE staff. Outdoor Play yard is directly outside of the classroom. Per ECE Dean, Tajmah, the staff who found the child notified her of the incident.

During today's inspection, LPA inspected the area where the incident took place. LPA spoke with ECE Dean, Tajmah, immediate actions were taken. Per conversation with ECE Dean, an action plan was created. All staff were reminded of the policies of supervision and hands on training was implemented. Parent of unsupervised child was notified.

Due to a potential health and safety risks for lack of supervision, a Type B deficiency has been issued. Please see LIC 809D for more details.

This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit. An exit interview was conducted with ECE Dean, Tajmah Martin, Director of Operations and Integration, Nathalie Carvajal, and Dean of Operations, Reyna Nieto.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/20/2023 03:19 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 10/20/2023 at 02:14 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: PRIMARY SCHOOL, THE
FACILITY NUMBER: 414004812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
101229 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(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation."

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Director has came up with an action plan to retrain all staff on policies and procedures for Supervision and transitions.

Director will continue to check in during trasitions to ensure the policies are being followed.
8
9
10
11
12
13
14
Based on interview and record review, the facility did not comply with the section cited above as facility self reported that there was a child left alone outside during transition back to the classroom from the outdoor play yard, which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Facility will have all staff review and acknowledge the written polices and procedure for supervision and transitionin, and send a copy of signed copies of each staff via email to LPA Tapia-Mandujano by 11/03/23.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2