380505779-5-28-2019-05-CC-AMAG-BDBVZ3-20190620165204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 380505779
Report Date: 05/22/2019
Date Signed: 05/28/2019 09:20:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/15/2019 and conducted by Evaluator Jennifer Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20190415102827

FACILITY NAME:	RAINBOW MONTESSORI		FACILITY NUMBER:	380505779
ADMINISTRATOR:	BAUER-CUSACK, CANDACE		FACILITY TYPE:	850
ADDRESS:	2358 24TH AVENUE		TELEPHONE:	(415) 661-9100
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94116
CAPACITY:	18	CENSUS: 13	DATE:	05/22/2019
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Candace Bauer-Cusack		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
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3
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5
6
7
8
9

Staff fed child an allergen

INVESTIGATION FINDINGS:

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5
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12
13

Licensing Program Analyst, LPA Yee conducted an inspection to close this complaint. There are 13 children and 3 staff members present today. During the course of the investigation, LPA interviewed complainant and three staff members. The child was allergic to dairy and ate a cupcake that contains milk at the school birthday party. The parent who made the cupcake said the cupcake does not have dairy in it at first, after the incident occurred, the center contacted the parent who made the cupcake and the parent realized the cake mix did have dairy in it. Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, (Title 22, Div 12 Chp1), are being cited on the attached LIC9099d. See next page for Type B citation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer Yee	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/15/2019 and conducted by Evaluator Jennifer Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20190415102827

FACILITY NAME:	RAINBOW MONTESSORI		FACILITY NUMBER:	380505779
ADMINISTRATOR:	BAUER-CUSACK, CANDACE		FACILITY TYPE:	850
ADDRESS:	2358 24TH AVENUE		TELEPHONE:	(415) 661-9100
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94116
CAPACITY:	18	CENSUS: 13	DATE:	05/22/2019
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Candace Bauer-Cusack		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to seek child timely medial attention

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst, LPA conducted an inspection to deliver the finding of the above allegation. During the course of the investigation, LPA interviewed complainant, three staff members, reviewed records and obtained records. The child had a cupcake that contained milk product at 11:45 am, there was no sign of allergic reaction after eating the cupcake that the staff was aware of. Parent picked up the child at 2:45 pm and pointed out the rash on the child's face. The staff said there was a small rash on the corner of the child's lip. Then, the staff heard the parent saying she will administer Benadryl to the child and left the facility.

Based on the information gathered, the child had a mild allergic reaction, therefore, the allegation is unsubstantiated.

This report has been reviewed by the site director.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer Yee	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 05-CC-20190415102827

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/22/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/22/2019 Section Cited CCR 101223(a)(2)	1 2 3 4 5 6 7	101223(a)(2)The licensee shall ensure that each child is accorded the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.	1 2 3 4 5 6 7	If the child is allergic to some products, staff would ask parents to let the facility know in advance and have another parent to bring substitute snacks. The deficiency has been corrected.
	8 9 10 11 12 13 14	A child is allergic to dairy products and ate a cupcake at the school birthday party. The parent who made the cupcake gave the wrong information to the staff which caused this incident. This requirement was not met as evidence-based upon LPA interviews. This poses a potential health risk to children in care.	8 9 10 11 12 13 14
	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: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer Yee	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019

LIC9099 (FAS) - (06/04)

Page: 2 of 3