384000303-4-11-2025-05-CC-HLEG-DFMP7U-20250411110433

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384000303
Report Date: 04/11/2025
Date Signed: 04/11/2025 11:04:40 AM

Document Has Been Signed on 04/11/2025 11:04 AM - 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:	JEWISH FAMILY PRESCHOOL-CONGREGATION BETH SHOLOM		FACILITY NUMBER:	384000303
ADMINISTRATOR/ DIRECTOR:	DALE KLEISLEY		FACILITY TYPE:	850
ADDRESS:	301 14TH AVENUE		TELEPHONE:	(415) 221-8736
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94118
CAPACITY: 76	TOTAL ENROLLED CHILDREN: 49	CENSUS: 38	DATE:	04/11/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:52 AM
MET WITH:	Dale Kleisley and Jamie Falkenhainer		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

NARRATIVE

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On April 11, 2025, Licensing Program Analyst (LPA) Leong conducted an unannounced case management visit regarding an incident that occurred on March 14, 2025. LPA met with Director Dale Kleisley (S1) and Assistant Director Jamie Falkenhainer (S2) and explained the purpose of the visit.

Thirty-eight children and sixteen staff members, including S1 and S2, were present at today's visit.

On March 14, 2025, staff noticed C1’s left eye was red and irritated. Staff immediately called C1’s mother, but no one responded. The staff contacted C1’s mother and father using the Brightwheel app. C1’s mother then reached out to the facility right away. After the staff finished talking with C1’s mother on the phone, they called 911. C1’s father arrived shortly after the conversation with C1’s mother. C1’s father went in the ambulance with the paramedics to accompany C1 to the hospital.

According to S1 and S2, C1 returned to the facility on March 17, 2025.

On March 24, 2025, the local regional office received an incident report regarding the incident on March 14, 2025. During today’s visit, LPA found out from S1 and S2 that the facility sent a written report to the local regional office on March 19. 2025, meeting the reporting requirements.

The incident will be cleared during today's visit.

A Notice of Site Visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Dale Kleisley.

Garfield Leung	TELEPHONE: (650) 266-8800
Hanson Leong	TELEPHONE: 650-266-8800
	DATE: 04/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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