210110748-9-28-2023-05-CC-HLEG-CW4PHA-20230928111937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210110748
Report Date: 09/28/2023
Date Signed: 09/28/2023 11:19:47 AM

Document Has Been Signed on 09/28/2023 11:19 AM - 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	PAPERMILL CREEK CHILDREN'S CORNER		FACILITY NUMBER:	210110748
ADMINISTRATOR:	LOURDES ROMO		FACILITY TYPE:	850
ADDRESS:	503 B STREET		TELEPHONE:	(415) 663-9114
CITY:	PT. REYES STATION	STATE: CA	ZIP CODE:	94956
CAPACITY:	35	CENSUS: 20	DATE:	09/28/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lourdes Romo		TIME COMPLETED:	11:30 AM

NARRATIVE

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On 9/28/2023, Licensing Program Analyst (LPA) Hanson Leong, made an unannounced case management visit to the child daycare facility listed above. The LPA was granted entry by the Director, Lourdes Romo. The purpose of the visit was to follow up on an incident involving a child climbing over a fence and leaving the facility on 9/21/2023. The LPA explained the purpose of the visit to Ms. Romo. All individuals listed on the facility’s roster have been granted permission to work or be present in a childcare facility. The LPA observed 5 staff members supervising 20 preschool aged children. The facility is operating within its capacity and in accordance with the required ratio of staff to children.

According to Ms. Romo, the incident occurred between music classes and free play. According to Ms. Romo, the child went up a wheel attached to the outdoor fence and the child walked over to the medical facility, which is in front of the facility. According to Ms. Romo, the child was found by a medical center employee. According to Ms. Romo, the facility removed the equipment from its original position that the child had climbed on after the incident.

The department determined that there was a lack of supervision when the child left the site alone and walked outside the school without the knowledge of the staff. This conclusion was reached based on the findings of the staff interview as well as the incident report that was received on 9/25/2023. A $500 civil penalty was assessed today for the lack of supervision that led to the event on 9/21/2023. (Refer to LIC 809D for citation)

Please refer to LIC 809D for today’s citation.

The LPA informed Ms. Romo to provide a copy of this licensing report dated 9/28/2023 that documents any Type A citations to the parents or guardians of all children currently enrolled by the next business day or the next day the children are in care, and to the parents or guardians of any newly enrolled children for a period. of 12 months from the date of this report. The deadline for providing this information is the next day, 9/29/2023, the children are in care. For the purposes of verification, the child's file needs to have either a signed Acknowledgement of Receipt of Licensing Report (LIC 9224) or another type of written statement.

A copy of today’s report and the facility’s appeal rights were given to Lourdes Romo. The Notice of Site Visit and the citation page, LIC 809D were given to Lourdes Romo and both must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with Lourdes Romo.

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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 09/28/2023 11:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PAPERMILL CREEK CHILDREN'S CORNER	FACILITY NUMBER: 210110748
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/29/2023 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	101229 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision...children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1).	1 2 3 4 5 6 7	The Director will have an all staff meeting on 9/29/2023 regarding the supervision incident on 9/21/2023. According to the Director, she will go over the child care regulations and health safety codes regarding supervision.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety, or personal rights risk to children in care.	8 9 10 11 12 13 14	A proof of attendance from all staff will be required. The proof of attendance must be submitted to the department by 9/29/2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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