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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 380503900
Report Date: 11/03/2022
Date Signed: 11/03/2022 11:37:40 AM

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
09/02/2022 and conducted by Evaluator Jennifer Yee
COMPLAINT CONTROL NUMBER: 05-CC-20220902151230
FACILITY NAME:YMCA OF SF., MISSION BRANCH, MISSION PRESCHOOLFACILITY NUMBER:
380503900
ADMINISTRATOR:ALVAREZ, KATIAFACILITY TYPE:
850
ADDRESS:4080 MISSION STREETTELEPHONE:
(415) 586-6900
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:42CENSUS: 28DATE:
11/03/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Katia AlvarezTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff used unusual form of punishment on day care child
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA Yee conducted an inspection to deliver the above complaint. The purpose of the inspection was explained.

During the course of the investigation, LPA interviewed 3 staff members and the Reporting Party. Interviews conducted confirmed the child was placed inside the bathroom and blocked with a cot to prevant him leaving the bathroom. Staff stated that this was done because the child was out of control and to protect the health and safety of other children, teachers and himself. Staff stated that this isolation was not intented as a form of punishment. LPA also obtained other relavent information and was reviewed.

Based on the information obtained, the preponderance of evidence standard has been met, therefore the above complaint has been determined to be SUBSTANTIATED. A copy of this report was discussed with the site director.

See next page for type B citation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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 2
Control Number 05-CC-20220902151230
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: YMCA OF SF., MISSION BRANCH, MISSION PRESCHOOL
FACILITY NUMBER: 380503900
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2022
Section Cited
CCR
101223(a)(3)
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101223 Personal Rights:
(a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. The requirement is not met as evidence by:
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Staff to be provided training & provide documents of training to CCL. Training to be completed by 11/17/2022.
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Based on interviews and information collected child was placed in the bathroom and blocked with a cot by facility staff. This poses potential health and safety 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 ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC9099 (FAS) - (06/04)
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