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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005024
Report Date: 10/28/2024
Date Signed: 10/28/2024 04:20:09 PM

Document Has Been Signed on 10/28/2024 04:20 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:SAN CARLOS-BELMONT AFTER SCHOOLFACILITY NUMBER:
414005024
ADMINISTRATOR/
DIRECTOR:		VIDUCIC, NANCYFACILITY TYPE:
840
ADDRESS:3100 ST. JAMES ROADTELEPHONE:
(650) 226-5031
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 150TOTAL ENROLLED CHILDREN: 120CENSUS: 67DATE:
10/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Jessica CummingsTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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On October 28, 2024, Licensing Program Analyst (LPA) Kassandra Medrano conducted an unannounced case management inspection. LPA met with director, Jessica and explained the purpose of the visit.

On October 17, 2024, Facility self reported to department of an incident that occurred. C1 was accidentally provided a food by a staff member, that C1 is allergic to, during program's hours of operation. C1 had an allergic reaction while on site. C1's parents were notified of incident right away and C1 received medical attention. Per director, the child returned to care the next day with no changes to care.

California Code of Regulations, Title 22, Division 12, Chapter 1 are being cited. Please refer to 9099D for more information.

Notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were also provided.

Exit interview conducted and report was reviewed with Director, Jessica Cummings.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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 10/28/2024 04:20 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 10/28/2024 at 03:49 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: SAN CARLOS-BELMONT AFTER SCHOOL
FACILITY NUMBER: 414005024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2024
Section Cited
CCR
101227(a)(7)(B)

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101227 Food Services (a)(7)(B) A child shall not be served any food to which the child's record indicates he/she has an allergy.
This requirement was not met as evidenced by:
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Formal staff meeting to include meeting agenda, the solutions discussed, staff attendance and staff signatures. Proof of formal meeting to be sent to RO before COB on 11/28/24
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Based on interview and record review, a staff member on site provided an enrolled child a food the child was allergic to, during hours of operation. This poses a potential health, safety or personal rights risk to children in care.
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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:Ali Zebila
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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