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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504984
Report Date: 09/18/2023
Date Signed: 09/18/2023 12:27:00 PM


Document Has Been Signed on 09/18/2023 12:27 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:KATHERINE MICHIELS SCHOOLFACILITY NUMBER:
380504984
ADMINISTRATOR:ANCHETA, YOLANDAFACILITY TYPE:
830
ADDRESS:1335 GUERRERO STREETTELEPHONE:
(415) 821-0130
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:15CENSUS: 14DATE:
09/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Maria Luna TIME COMPLETED:
12:30 PM
NARRATIVE
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On 9/18/2023 at 9:00AM., Licensing Program Analyst (LPA) Luis J. Gomez met with Administrator, Maria Luna. Purpose of this report is to cite facility for deficiencies observed during an unannounced, 10 day complaint inspection. Present was the administrator and 4 staff caring for 14 children. LPA inspected facility for health and safety hazards.

At 9:28AM., Based on observations, LPA confirmed two infant bouncers located in infant playroom.



Based on today’s inspection, deficiencies were observed in areas evacuated according to the Title 22, Division 12, Chap, 1 of Ca, Code of Regulations and cited on the 809D. An exit interview, report, appeal rights, and plan of correction was discussed with the administrator, Maria Luna and signature of this form acknowledges the receipt of these documents.

Civil Penalty of $250.00 was issued for repeat violation.

A copy of this report and appeal rights were reviewed and provided to the administrator.
Notice of site visit was given and shall remain posted for 30 days.
SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023
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 09/18/2023 12:27 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: KATHERINE MICHIELS SCHOOL
FACILITY NUMBER: 380504984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2023
Section Cited
CCR
101439(d)(2)

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101439(d)(2)(d) Infant Care Center Fixtures, Furniture, Equipment and Supplies: Swings, playpens and all such equipment and furniture shall be assembled or installed according to the manufacturer's instructions, and shall be maintained in good repair and safe condition. (2) A baby walker shall not be allowed on the premises of a child care center in accordance with Health and Safety Code Section 1596.846. This requirement is not met as evidenced by:
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Facility will remove baby bouncers (chairs) from facility by due date: 9/19/2023.
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At 9:28AM., Based on observations, LPA confirmed two infant bouncers located in infant playroom. This poses a potential health and safety risk to children in care.
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Proof of corrections will be submitted to the Department via email.

Civil Penalty of $250.00 was issued for repeat violation.

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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: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023
LIC809 (FAS) - (06/04)
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