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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380505334
Report Date: 11/04/2019
Date Signed: 11/04/2019 02:28:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SFUSD-NORIEGA (EES) SCHOOL AGEFACILITY NUMBER:
380505334
ADMINISTRATOR:NG, IVYFACILITY TYPE:
840
ADDRESS:1775 44TH-AVENUETELEPHONE:
(415) 759-2853
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:112CENSUS: 37DATE:
11/04/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Ivy NgTIME COMPLETED:
02:45 PM
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On November 04, 2019, at approximately 1:45 PM, Licensing Program Analyst (LPA) Winnie Ly conducted an Unannounced Case Management Inspection to follow up on the self reported Unusual Incident Report the Department received on October 25, 2019 for an incident that occurred on October 24, 2019. Present at the facility were Principal Ivy Ng, 5 staff and 37 school age children.

According to the unusual incident report, a child tripped and bumped herself by the steps of the play structure. She had a slight scratch on the forehead and bleeding nose. Parents were notified. When mother arrived, she asked the school to call 911 due to the amount of blood the child bled for bleeding nose. The school called 911. When paramedic arrived, the nose bleed had stopped. The child was conscious and was able to answered all the questions asked by paramedic. Paramedic determined the child did not need to be transported to the emergency. The family took the child to their doctor following the incident. The following day, the family notified the school that the child would not be returning to school for one day due to having doctor appointment. The child returned to school the following Monday. Per Principal, the child was reported to be healthy and fine after being checked out by her doctor.

No deficiencies were issued today under Title 22 Division 12 of the Ca. Code of Regulations. Notice of Site Visit was posted. Notice to remain posted for 30 days. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie LyTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2019
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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