380505568-5-31-2023-05-CC-AZEA-CSTMCM-20230615092946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 380505568
Report Date: 05/31/2023
Date Signed: 05/31/2023 12:46:24 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 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
03/15/2023 and conducted by Evaluator Luis Gomez

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20230315165513

FACILITY NAME:	FAMILY DEVELOPMENTAL CENTER (PRESCHOOL)		FACILITY NUMBER:	380505568
ADMINISTRATOR:	QUIROZ, YOHANA		FACILITY TYPE:	850
ADDRESS:	2730 BRYANT STREET		TELEPHONE:	(415) 282-1090
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94110
CAPACITY:	83	CENSUS:	DATE:	05/31/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Dee Lee		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to day care child resulting in day care child sustaining an injury.

INVESTIGATION FINDINGS:

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On 5/31/2023 at 8:55AM., Licensing Program Analyst (LPA) Luis J. Gomez met with Administrative Director, Dee Lee. Purpose of the inspection was explained and was for an Unannounced, Complaint Investigation. Present was the Administrative Director and 13 staff caring for 46 children. LPA inspected facility for health and safety hazards.

During inspection, LPA performed site observations, interviews and reviewed facility records.

During the course of this investigation, observations were conducted on 5/12/2023 and 5/31/2023. A review of the facility records was complete, which included the staff records, children records, and parent handbook. LPA conducted interviews staff, director and involved parties. (REFER TO LIC9099C, FOR CONT.)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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 5

Control Number 05-CC-20230315165513

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: FAMILY DEVELOPMENTAL CENTER (PRESCHOOL)	FACILITY NUMBER: 380505568
	VISIT DATE: 05/31/2023

NARRATIVE

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(Page 2)
Regarding the allegations of staff did not provide adequate supervision to day care child resulting in day care child sustaining an injury; Based on interviews, observations, and record review; LPA determined allegation made is valid. Therefore, the preponderance of evidence standard has been met, with allegations found to be SUBSTANTIATED. California code of Regulations (Title 22, Section 12 Chapter 1) are being cited on attached 9099D.

Notice of site visit was provided to the facility.

Website for Forms and Regulations: www.ccld.ca.gov. Appeal rights were provided to licensee.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 05-CC-20230315165513

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: FAMILY DEVELOPMENTAL CENTER (PRESCHOOL)	FACILITY NUMBER: 380505568
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/12/2023 Section Cited CCR 101229(a)	1 2 3 4 5 6 7	101229(a) Responsible for providing care and supervision: (a) The licensee shall provide care and supervision as necessary to meet the children's needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Director will conducted training with staff to review children's behavior support plans, and proper protocols/ procedures for supervision.
	8 9 10 11 12 13 14	Based on observations, record review and interviews, LPA determined staff did not provide adequate supervision to day care child resulting in day care child sustaining an injury. This poses a potential health and safety risk to children in care.	8 9 10 11 12 13 14	Director will submit facility rules for use of the outdoor area and structure. Staff schedule, roles and responsibilities will be submitted to the department by the due date: 6/12/2023.
	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.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC9099 (FAS) - (06/04)

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