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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384000958
Report Date: 12/15/2021
Date Signed: 12/15/2021 11:52:54 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:FAMILY SCHOOL CDC BERNAL GATEWAY, THEFACILITY NUMBER:
384000958
ADMINISTRATOR:HAYNES, MARILYNFACILITY TYPE:
830
ADDRESS:3101 MISSION STREETTELEPHONE:
(415) 550-4178
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:16CENSUS: 10DATE:
12/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Amelia Justo, Patricia BacceraTIME COMPLETED:
10:45 AM
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 12/15/2021 at 8:40A.M., Licensing Program Analyst's (LPA) Luis J. Gomez met with Site Supervisor, Amelia Justo. Program Director, Patricia Bacerra arrived during inspection. Purpose of inspection was explained and was an unannounced, Case Management inspection, in response to an unusual incident report received by the Department on 11/18/2021. At 8:45A.M. LPA observed staff member present without proper criminal record clearance or association. Deficiency was issued on Case Management report. Present was the Program Director, Site Supervisor and 6 staff supervising 17 children. LPA inspected facility with Program Director for health and safety hazards.

Director self- reported that on 11/18/2021, that day-care child, C1, had eloped from the toddler classroom and found by staff several minutes later. During inspection, LPA reviewed staff's written statements with Program Director. Based on the information collected, it was determined that a lack of supervision had occurred on 11/18/2021, with staff not maintaining direct visual supervision of children at all times.

In response to this incident, Program Director has installed new child safety gate and ring alarm system in facility entry way leading to the toddler classroom. Additional cameras have also been installed in each of the classrooms.

Based on today’s inspection, a deficiency was observed in the areas evacuated and cited according the Title 22 Division 12 of Ca. Code of Regulations and listed on the 809- D. An exit interview was conducted with Program Director and plan of correction was discussed. A copy of this report with the appeal rights was provided, and signature of this form acknowledges the receipt of these documents.

Notice of site visit was observed to be posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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: FAMILY SCHOOL CDC BERNAL GATEWAY, THE
FACILITY NUMBER: 384000958
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2021
Section Cited

1
2
3
4
5
6
7
101229(a)(1)Responsible for providing Care and Supervision: No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on interviews and file review, LPA confirmed child in care was left without visional staff supervision for several minutes. This poses a potential health and safety risk to children in care.
8
9
10
11
12
13
14
Deficiency was cleared during inspection.

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: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2