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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414004812
Report Date: 12/19/2023
Date Signed: 12/19/2023 04:09:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2023 and conducted by Evaluator Leslit Tapia-Mandujano
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20230922120230
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:98CENSUS: 0DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:ECE Tajmah MartinTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff used an inappropriate action to capture a child’s attention.
INVESTIGATION FINDINGS:
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Due to facility being on winter break, LPA Tapia-Mandujano delivered the findings of the investigation to ECE Dean Tajmah Martin via phone on December 19th, 2023 at approximately 2:30pm. Complaint was received by the Department on 09/22/23.

During the course of the investigation, health and safety inspections and staff interviews were conducted. LPA also received pertinent documents. Due to the information that was received, LPA determined that a staff member got down to the childs’ level and placed hand under the childs’ chin to capture the childs’ attention, which may be perceived as inappropriate.

Based on LPA’s observations, interviews, and record review which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1, are being cited. Please refer to 9099D for more information.

Upon receipt of this report, Facility shall post the Notice of Site Visit. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain postings as required will result in an immediate $100 civil penalty. This report is public and can be reviewed.

After today’s phone call, an exit interview was conducted, report was emailed with Appeal Rights and Procedures to ECE Dean Tajmah Martin at tajmah.martin@theprimaryschool.org. ECE Dean, Tajmah Martin has acknowledged receipt of report and a signed copy of the report will be received at a later date.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 05-CC-20230922120230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PRIMARY SCHOOL, THE
FACILITY NUMBER: 414004812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
101223(a)(1)
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101223(a)(1): Personal Rights: The licensee shall ensure that each child is accorded the following personal rights: To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement was not met by:
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LPA has provided a copy of personal right's regulations to ECE Dean Tajmah Martin. ECE Dean agrees that she will conduct an all staff training about Personal Right’s.

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Based on interviews and record review, the facility did not comply with the section cited above as a staff use an inappropriate action to capture a childs’ attention which poses a potential health, safety or personal rights risk to persons in care.
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Facility will have all staff review and acknowledge the written polices and procedure for Childrens personal Rights and send a copy of agenda and signed copies of each staff via email to LPA Tapia-Mandujano by 01/19/23.
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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.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
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