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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414004859
Report Date: 02/08/2023
Date Signed: 02/08/2023 04:54:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PENINSULA CHILD CARE, 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
11/29/2022 and conducted by Evaluator Leslit Tapia-Mandujano
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20221129105011
FACILITY NAME:JIMENEZ, ANDREAFACILITY NUMBER:
414004859
ADMINISTRATOR:JIMENEZ, ANDREAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 454-7249
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:14CENSUS: 6DATE:
02/08/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Licensee, Andrea JimenezTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Licensee does not provide proper supervision to children in care.
INVESTIGATION FINDINGS:
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On February 8th, 2023 at approximately 2:45pm, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced inspection and met with Licensee, Andrea Jimenez. Purpose of the inspection was explained, and it was to report the investigation findings for the above allegation. Complaint was received by the Department on 11/29/22. Present in the facility are Licensee and staff caring for 6 children (3 infants, 2 preschool age, and 1 school age).

During today's inspection, LPA interviewed stadd and LPA and licensee inspected the facility for health and safety hazards.

During the Investigation, LPA conducted file review, interviews with staff, parents, and parties involved. , and received pertinent documentation. During the course of the investigation, LPA determined that proper supervision was not provided to children in care.



Continued on Page 2...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
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 3
Control Number 05-CC-20221129105011
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JIMENEZ, ANDREA
FACILITY NUMBER: 414004859
VISIT DATE: 02/08/2023
NARRATIVE
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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 visit, an exit interview was conducted with Licensee, Andrea Jimenez. A copy of this report was reviewed and provided to licensee.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 05-CC-20221129105011
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JIMENEZ, ANDREA
FACILITY NUMBER: 414004859
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited
CCR
102423(a)(2)
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02423(a)(2): Personal Rights: Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged...(2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not me by:
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Licensee has agreed to have all staff train in supervision.

Licensee will provide docuemntaition of completion of training by 03/10/23.
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Based on observation, interviews, and record review, the licensee did not comply with the section cited above as proper supervision was not provided to the children in care, which poses a potential health, safety or personal rights risk to persons in care.
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An informail office meeting will be scheduled to discuss the deficiencies.
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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: Ali Zebila
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3