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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004812
Report Date: 11/14/2024
Date Signed: 11/14/2024 04:04:54 PM

Document Has Been Signed on 11/14/2024 04:04 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/
DIRECTOR:		MARTIN, TAJMAHFACILITY TYPE:
850
ADDRESS:2086 CLARKE AVENUETELEPHONE:
(650) 396-2779
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 98TOTAL ENROLLED CHILDREN: 98CENSUS: DATE:
11/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:ECE Director, Tajmah Martin and Director of Operations, Reyna NietoTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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On November 14th, 2024 at approximately 11:25am, Licensing Program Analyst (LPAs) Tapia-Mandujano and Naves arrived at the facility to conduct a Case Management-Incident inspection. LPAs met with ECE Director, Tajmah Martin and Director of Operations, Reyna Nieto. The purpose of today's inspection was explained. Inspection is in response to an Unusual Incident Report that was self reported and received by the department on November 8th, 2024.

Facility operates in Classrooms #3,4,5,6,7, and 12. LPAs inspected the classroom and outdoor area where the incident happen as well as conducted a Health and Safety Inspection of all the classroom.

The facility self reported an incident that occurred on November 6th, 2024. The incident involved lack of supervision that resulted in a child being left unsupervised outside of the classroom. Per interview and record review of incident received, a child was left alone outside of the classroom for approximately 2 minutes. Based on interviews conducted, a substitute staff contracted by a Third Party Agency left a child outside although they were told to "stay with the child". Per ECE Manager, Brenda Quezada, she was called for extra support for this child and when she arrived to support, she found the child alone outside and brought the child back in. Parent of unsupervised child was notified.

During today's inspection, LPA spoke with ECE Director, Tajmah, about the immediate actions that were taken. Per conversation with ECE Director, immediate action that was taken was installing baby gates to the doors, having a third teacher in that classroom, and reiterating the policies and procedures.

Due to the repeat violation, a Type A deficiency has been issued and civil penalties were assessed. Please see LIC 809D for more details.


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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 11/14/2024
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Deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

LPAs informed ECE Director, Tajmah Martin that this report dated 11/14/24 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 11/14/24 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 Director, Tajmah Martin and Director of Operations, Reyna Nieto
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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Document Has Been Signed on 11/14/2024 04:04 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 11/14/2024 at 02:54 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: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2024
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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Facility conducted an investigation plan and took immediate action based on internal policies and procedures.

Facility will also implement a new process and/or procedure to train staff who are outsourced from a third party agency to ensure they understand the policies and procedures that are in place prior to being placed in a classroom.
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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 outside the classroom transitioning from outdoor play, which poses an immediate health, safety or personal rights risk to persons in care.
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Facility will email LPA Tapia-Mandujano a copy of the policies and/or procedures that was created for outsourced staff by


Civil Penalties were assessed.

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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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


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