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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504406
Report Date: 04/03/2024
Date Signed: 04/03/2024 01:13:09 PM


Document Has Been Signed on 04/03/2024 01:13 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SFUSD-SAN MIGUEL EARLY EDUCATION SCHOOL (PS)FACILITY NUMBER:
380504406
ADMINISTRATOR:ANITA TONG, DIRECTORFACILITY TYPE:
850
ADDRESS:300 SENECA AVENUETELEPHONE:
(415) 469-4756
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:102CENSUS: 88DATE:
04/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Anita TongTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst, LPA Yee conducted a case management visit today. This is a self-reported incident that occurred on 3/12/2024, and 3/14/2024. Today, there were 88 children and 15 teachers on site. The lead teacher, Ms. Hernandez was interviewed. On 3/12/2024, approximately at 2:40 pm, after children woke up from their naps, a teacher took a group of children to the bathroom and left one child behind. The child was crying in the bathroom, was discovered by another teacher, and brought the child back to the classroom. How long the child was left behind is unknown.

On 03/14/2024, the same teacher took another child to the bathroom and did not bring the child back to the classroom.

Both children were safe and unharmed on both occasions.

Based on the interviews conducted today, there was a lack of supervision on both occasions. Therefore, a type B citation was issued today.

See the next page for citations.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/03/2024 01:13 PM - 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: SFUSD-SAN MIGUEL EARLY EDUCATION SCHOOL (PS)
FACILITY NUMBER: 380504406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2024
Section Cited
CCR
101223

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101223 Personal Rights. 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. This requirement was not met as evidenced by:
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The facility's representative stated that refresher training has been conducted with that individual teacher on 3/22. In additional another refresher training will be conducted by the end of this month.

Updated facility schedule will be submitted to LPA.
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Based on information collected from today's visit, LPA determine child's personal rights was violated on both days. This poses a 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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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