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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004812
Report Date: 02/12/2024
Date Signed: 02/12/2024 02:33:21 PM

Document Has Been Signed on 02/12/2024 02:33 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: 94CENSUS: 78DATE:
02/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:ECE Dean, Tajmah Martin and Dean of Operations, Reyna NietoTIME COMPLETED:
02:50 PM
NARRATIVE
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On February 12th, 2024 at approximately 1pm, Licensing Program Analyst, (LPA) Tapia-Mandujano arrived at the facility for a Case Management-Incident inspection. LPA met with ECE Dean, Tajmah Martin and Dean of Operations, Reyna Nieto. The purpose of today's inspection was explained. Inspection is in response to an Unusual Incident Report that was called in and received by the department on January 22nd, 2024.

Facility operates in Classrooms #3,4,5,6,7, and 12. Present in the facility are ECE Directors and 16 staff supervising 78 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 occurred on January 19th, 2024. The incident involved lack of supervision that resulted in a child being left unsupervised inside of the classroom. Per interview and record review of incident received, children were outdoor playing and a group of children walked inside the classroom to grab jackets with a substitute teacher. Substitute teacher and the other children left the classroom to go back to the outdoor play yard that is directly outside of the classrooms. Per ECE Director, another staff saw the door open to the classroom and closed the door without realizing a child was inside. Per ECE Director, another staff coming from her break walked in about 1-2 minutes later and took the child back outside to join the rest of the group in the outdoor play yard.

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.



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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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 02/12/2024 02:33 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 02/12/2024 at 01:43 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: 02/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2024
Section Cited
CCR
101229(a)(1)

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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:
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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.
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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 inside the classroom during outdoor play, which poses an immediate health, safety or personal rights risk to persons in care.
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LPA recieved a copy of Action Plan with all staff members signatures and the Transition Plans for each classroom.

Office Meeting may be scheduled for a later time.

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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:Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 02/12/2024
NARRATIVE
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Due to it being a repeat violation, a Type A deficiency has been issued and civil penalties were assessed. Please see LIC 809D for more details.

Deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

LPAs informed ECE Director, Tajmah Martin that this report dated 02/12/24 documents a Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPAs informed the ECE Director, Tajmah Martin to provide a copy of this licensing report dated 02/12/24 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.


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 and Dean of Operations, Reyna Nieto.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
LIC809 (FAS) - (06/04)
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