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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 384001604
Report Date: 12/05/2019
Date Signed: 12/06/2019 09:42:32 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
10/01/2019 and conducted by Evaluator Winnie Ly
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20191001091853
FACILITY NAME:STAR OF THE SEA PRESCHOOLFACILITY NUMBER:
384001604
ADMINISTRATOR:PARAS, JACQUELINE M.FACILITY TYPE:
850
ADDRESS:360 NINTH AVENUETELEPHONE:
(415) 221-7449
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY:30CENSUS: 20DATE:
12/05/2019
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ersie ArbanTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff files are incomplete.
Facility operates out of ratio.
Child injured by another child while in care.
Staff failed to inform child's authorized representative of injuries.
INVESTIGATION FINDINGS:
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On December 05, 2019, at approximately 8:30am, Licensing Program Analyst (LPA) Winnie Ly conducted an unannounced visit to deliver complaint findings and met with Head Teacher Ersie Arban. Purpose of the inspection was explained. There were also 20 children and 2 teacher assistants present during the visit.

Based on LPA reviewed of staff files, the preponderance evidenced standard has been met. Therefore, the allegation staff files are incomplete is found to be SUBSTANTIATED. California Code and Regulations Title 22, Division 12 and Chapter 1 was cited with a Type B violation was issued on October 4, 2019 for allegation staff files are incomplete.

CONTINUED>>>
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie LyTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2019
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 4
Control Number 05-CC-20191001091853
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: STAR OF THE SEA PRESCHOOL
FACILITY NUMBER: 384001604
VISIT DATE: 12/05/2019
NARRATIVE
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Page 2....

Based on information revealed through interviews of staff and information LPA collected during investigation, the preponderance evidenced standard has been met. Therefore, the allegations Facility operates out of ratio, Child injured by another child while in care, Staff failed to inform child's authorized representative of injuries are found to be SUBSTANTIATED. California Code and Regulations Title 22, Division 12 and Chapter 1 are being cited with Type B violation issued today on the attached LIC 9099D.

An exit interview was conducted and Plans of Corrections (POC) were developed and reviewed with Head Teacher. A copy of this report and appeal rights were discussed and left with Head Teacher whose signature on this form confirm receipt of these reports.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie LyTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 05-CC-20191001091853
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: STAR OF THE SEA PRESCHOOL
FACILITY NUMBER: 384001604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2019
Section Cited
CCR
101216.3(b)(1)
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101216.3 Teacher-Child Ratio
(1) A ratio of one fully qualified teacher and one aide for every 18 children in attendance in a preschool program is allowed when the aide meets the qualifications. This requirement is not met evidenced by:
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Two teacher assistants are working toward completing the core courses requirement.

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Based on LPA interviews staff, teacher assistant was left alone to care for 18 children. This poses a potential health and safety risk to children in care.
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Head Teacher will send proof of on going education from Aides to LPA by 12/19/2019.
Type B
12/19/2019
Section Cited
CCR
101229(a)(b)
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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. This requirement is not met evidenced by:

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Director or Head Teacher must ensure children must be supervised at all time.

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Based on information collected during interviews of staff, staff did not see a child was injured but assumed child was hurt by another child. Ice was was given to child after incident when child's cheek was noticeably red. This poses a potential health and safety risk to children in care.
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Director or Head Teacher must submit a plan of how they will assign an area to each teacher to make sure every area in the classrom will have a teacher supervising children by 12/19/2019.
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 ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie LyTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2019
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 05-CC-20191001091853
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: STAR OF THE SEA PRESCHOOL
FACILITY NUMBER: 384001604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2019
Section Cited
CCR
101212(d)(1)(b)
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101212 Reporting Requirements
(a) Each licensee or applicant shall furnish to the Department reports as required by the Department including, but not limited to, the following:
Any injury to any child that requires medical treatment. This requirement is not met evidenced by:
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Director or Head Teacher agrees to have a staff training letting staff know the requirement of reporting any injury of children in care.
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Based on LPA information collected during the investigation and interviews of staff, child was injured in care and parent was not fully informed. LPA did not see "ouch report" in child's file. This poses a potential health and safety risk to children in care.
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Proof of training must be send to LPA by 12/19/2019.
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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: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie LyTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2019
LIC9099 (FAS) - (06/04)
Page: 4 of 4