213001117-1-10-2023-05-CC-DJOO-CMZUXF-20230112145815

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 213001117
Report Date: 01/10/2023
Date Signed: 01/10/2023 12:59:25 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/28/2022 and conducted by Evaluator Hanson Leong

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20221128170750

FACILITY NAME:	JCC PRESCHOOL SAN RAFAEL		FACILITY NUMBER:	213001117
ADMINISTRATOR:	RACHEL FALK		FACILITY TYPE:	850
ADDRESS:	200 N. SAN PEDRO ROAD		TELEPHONE:	(415) 444-8044
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	150	CENSUS: 0	DATE:	01/10/2023
		ANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Erin Burns		TIME COMPLETED:	01:14 PM

ALLEGATION(S):

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9

-Staff did not ensure that facility fence did not pose a hazard to day care children while in care.

INVESTIGATION FINDINGS:

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On 01/10/2023, Licensing Program Analyst (LPA), Hanson Leong, made an announced conclusionary complaint visit to the house of the director. The facility was closed due to inclement weather.. The LPA explained the purpose of the visit to the director.

All relevant information was gathered and analyzed during the LPA investigation, and all parties involved were contacted and interviewed. Based on information obtained from the LPA investigation, the preponderance of evidence standard has been met, therefore the above allegation, staff did not ensure that facility fence did not pose a hazard to day care children while in care, is found to be substantiated.

A copy of this report, the “Notice of Site Visit,” and their appeal rights were given to the director. The "Notice of Site Visit” shall be posted for 30 days. Failure to maintain postings as required, will result in an immediate $100 civil penalty. Exit interview conducted and report was reviewed with the Director, Erin Burns

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

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 4

Control Number 05-CC-20221128170750

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: JCC PRESCHOOL SAN RAFAEL	FACILITY NUMBER: 213001117
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/10/2023 Section Cited CCR 101229(a)	1 2 3 4 5 6 7	101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs.	1 2 3 4 5 6 7	A meeting with the staff in regards to the supervistion will be conducted
	8 9 10 11 12 13 14	According to the interviews, staff failed to ensure that the facility fence did not pose a hazard to day care children while they were in care. was substantiated, therefore it posed a potential health and safety risk to children in care.	8 9 10 11 12 13 14
	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: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/28/2022 and conducted by Evaluator Hanson Leong

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20221128170750

FACILITY NAME:	JCC PRESCHOOL SAN RAFAEL		FACILITY NUMBER:	213001117
ADMINISTRATOR:	RACHEL FALK		FACILITY TYPE:	850
ADDRESS:	200 N. SAN PEDRO ROAD		TELEPHONE:	(415) 444-8044
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	150	CENSUS: 0	DATE:	01/10/2023
		ANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Erin Burns		TIME COMPLETED:	01:14 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

- Staff did not ensure that facility playground ledge did not pose a hazard to day care children in care.

- Staff left day care child unattended while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/10/2023, Licensing Program Analyst (LPA), Hanson Leong, made an announced conclusionary complaint visit to the house of the director. The facility was closed due to inclement weather.The LPA explained the purpose of the visit to the director.

All relevant information was gathered and analyzed during the investigation, and all parties involved were contacted and interviewed. .Based on information obtained from the LPA investigation, the allegations, staff did not ensure that facility playground ledge did not pose a hazard to day care children in care and staff left day care child unattended while in care, may have happened or are valid, there is not a preponderance of evidence to prove the violation did or did not occur; therefore, the above allegations are found to be unsubstantiated.

A copy of this report and the “Notice of Site Visit” were given to the director . “The Notice of Site Visit” shall be posted for 30 days. Failure to maintain postings as required, will result in an immediate $100 civil penalty. Exit interview conducted and report was reviewed with the Director, Erin Burns.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4