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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380505779
Report Date: 04/23/2019
Date Signed: 04/23/2019 10:16:24 AM

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:RAINBOW MONTESSORIFACILITY NUMBER:
380505779
ADMINISTRATOR:BAUER-CUSACK, CANDACEFACILITY TYPE:
850
ADDRESS:2358 24TH AVENUETELEPHONE:
(415) 661-9100
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:18CENSUS: 17DATE:
04/23/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rosa-Maria VenegasTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst, LPA Yee conducted a case management inspection today. The purpose of the inspection has been discussed. Today, LPA interviewed three staff members.

Staff stated that on 4/10/2019, a child had an allergic reaction after eating a cupcake. Prior to this incident, the director verified with the parent who brought the cupcake over said there's no dairy product in the cupcake. The parent said he made the cupcake himself and the cupcake does not contain any dairy product. However, the parent who made the cupcakes failed to review the cake mix that had a dairy product in it.

After this incident, the facility failed to report this incident to CCL. Staff said she was not aware of the reporting requirements. Report requirements have been discussed. A copy of the incident report was obtained today.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2019
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: RAINBOW MONTESSORI
FACILITY NUMBER: 380505779
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/23/2019
Section Cited
CCR
101212(d)(1)(B)
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101212Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours, Any injury to any child that requires medical treatment.
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LPA obtained incident report during the inspection.

Deficiency has been corrected.
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On 4/10 a child had an allegic reaction after eating a cup cake that containe dairy and the facility failed to report this incident to CCL.

This requirement was not met as evidence-based upon interviews. This poses a potential health 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: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2019
LIC809 (FAS) - (06/04)
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