<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380505725
Report Date: 09/25/2024
Date Signed: 09/25/2024 05:01:12 PM


Document Has Been Signed on 09/25/2024 05:01 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:ST. NICHOLAS DAY CARE AND PRESCHOOL-INFANTFACILITY NUMBER:
380505725
ADMINISTRATOR:TUWAI, KATHYFACILITY TYPE:
830
ADDRESS:5200 DIAMOND HEIGHTS BLVD.TELEPHONE:
(415) 550-1536
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94131
CAPACITY:39CENSUS: 29DATE:
09/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Sheron Singh & Kathy TuwaiTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On September 25, 2024 at approximately 3:05pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, case management visit in regards to an incident that was self-reported to department September 6, 2024. LPA met with administrative assistant, Sheron Signh, and explained the purpose of the visit.

Facility is a combination center with an infant program and a preschool program. Under infant license, present during visit included 29 children with 9 teaching staff.

On September 5, 2024, Teacher 1 (T1) was present in the infant classroom with 4 other teaching staff and 16 infants. Per T1, children are "grouped" to a specific teaching staff member while in infant classroom. On date of incident, T1 had a group of 3 infants, including Child 1(C1).

C1 was bottle fed by T1 once on the date of incident. At approximately 11:30am, C1 was bottle fed approximately 2 oz. of milk from C1's assigned bottle brought from home. At approximately 12:40pm, C1 was bottle fed approximately 4 oz. of milk from a different enrolled infant's bottle. At approximately 2:30pm, C1 was picked up from facility. On same date, C1's authorized representative informed director that C1 was incorrectly bottle fed and was given milk that did not belong to C1. Per administrative assistant, C1 no longer attends facility.

During today's visit, LPA inspected food and milk preparation area in infant classroom. LPA observed infants' bottles to be labeled with assigned infants' names. LPA observed containers storing bottles to also be labeled with assigned infants' names. LPA also observed C1's individual feeding plan that specified the type of food and frequency to be given to C1.

LPA determined C1 was bottle fed incorrectly. Staff did not feed C1 in accordance to C1's feeding plan, therefore facility is being cited under Title 22, Division 12, Chapter 1. See 809D for details. A hard copy of this report was provided during visit as well as appeal rights.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with director, Kathy Tuwai.
SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
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 09/25/2024 05:01 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: ST. NICHOLAS DAY CARE AND PRESCHOOL-INFANT
FACILITY NUMBER: 380505725

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2024
Section Cited
CCR
101427(c)

1
2
3
4
5
6
7
101427 Infant Care Food Service (c) The infant shall be fed in accordance with the individual plan.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Director held a one on one meeting with T1. T1 was issued a warning by director. Director held an informal meeting with staff reminding infant feeding protocols. An all infant staff meeting is to occur, re-training staff on infants' individual feeding plans.
8
9
10
11
12
13
14
Based on interviews and record review, C1 was fed an incorrect bottle that did not belong to C1. This poses a potential health, safety or personal rights risk to children in care.
8
9
10
11
12
13
14
Proof of training that includes topics discussed, feeding protocols and signatures of the infant staff attending training is to be sent to LPA no later than POC due date.

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.
SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2