384001312-7-22-2021-05-CC-AZEA-C5QRCE-20210809125412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 384001312
Report Date: 07/22/2021
Date Signed: 07/22/2021 11:17:41 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
05/10/2021 and conducted by Evaluator Cindy Mok

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20210510161140

FACILITY NAME:	SHALOM SCHOOL		FACILITY NUMBER:	384001312
ADMINISTRATOR:	HINDA LINGAR		FACILITY TYPE:	850
ADDRESS:	862 28TH AVENUE		TELEPHONE:	(415) 831-8399
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94121
CAPACITY:	36	CENSUS: 21	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Ella Kasminskaya & Vika Levina		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff are not adequately supervising day care children at the public playground.

INVESTIGATION FINDINGS:

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LPA Mok conducted an inspection to finalize the complaint with the Site Directors, Ella Kasminskayaz & Vika Levina. The purpose of the inspection was explained to her. LPA conducted observation during the investigation. Based on the LPA's observation, a lack of supervision occurred when two teachers were responsible for supervising a group of preschoolers at Fulton playground; teachers were leaving children unattended without direct visual observation.

Based on LPAs observation which was 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, Division 12 & Chapter 3), are being cited on the attached LIC 9099D.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Mok	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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
05/10/2021 and conducted by Evaluator Cindy Mok

COMPLAINT CONTROL NUMBER: 05-CC-20210510161140

FACILITY NAME:	SHALOM SCHOOL		FACILITY NUMBER:	384001312
ADMINISTRATOR:	HINDA LINGAR		FACILITY TYPE:	850
ADDRESS:	862 28TH AVENUE		TELEPHONE:	(415) 831-8399
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94121
CAPACITY:	36	CENSUS:	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Ella Kasminskaya & Vika Levina		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff left the daycare children .behind at the public playground

INVESTIGATION FINDINGS:

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

LPA Mok conducted an inspection to finalize the complaint with the Site Directors, Ella Kasminskaya & Vika Levina. The purpose of the inspection was explained to her. LPA conducted observation during the investigation. Based on the LPA's observation, there was no sufficient evidence to prove the staff left the daycare children behind at the public playground or not.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore the allegation is Unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Mok	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 05-CC-20210510161140

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: SHALOM SCHOOL	FACILITY NUMBER: 384001312
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/28/2021 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	101229 Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) 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.	1 2 3 4 5 6 7	Director ensures all staff providing care and supervision to the children at all times. Director needs to conduct the training to current staff about effective care and supervision. Director needs to submit a copy of the training material and attendance sheet for staff by the due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by confirmation that a lack of supervision occurred when two teachers were responsible for supervising a group of preschoolers at Fulton playground; teachers left children unattended without direct visual observation. Not providing direct visual observation to the children presents immediate health and safety risks to them.	8 9 10 11 12 13 14	office meeting may be scheduled.
	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: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Mok	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

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