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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001605
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:11:56 PM


Document Has Been Signed on 05/12/2022 12:11 PM - It Cannot Be Edited

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:FORDE, KELLY E.FACILITY NUMBER:
384001605
ADMINISTRATOR:FORDE, KELLY E.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 641-4123
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94131
CAPACITY:14CENSUS: 12DATE:
05/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kelly FordeTIME COMPLETED:
12:45 PM
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
T1= Teacher #1, T2= Teacher #2, C1= Child 1.

On May 12, 2022 at approximately 9:00am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, case management visit. LPA met with licensee, Kelly Forde and explained the purpose of the visit.

The case management regarded an unusual incident that was self reported to CCLD on May 4, 2022. On May 4, 2022 at approximately 10:40am, an enrolled child (C1) was left unattended and unsupervised by licensee and/or licensee's staff in a public setting, outside and away from licensee's licensed family child care home.

On date of incident, licensee, T1, T2 and 10 enrolled children (all preschool age) conducted a neighborhood walk from licensee's family child care home to local park. Neighborhood walk passed through local homes, local shopping center and local preschool (not related to or associated to licensee). Without licensee, T1 or T2's knowledge, C1 was separated from group during neighborhood walk. Licensee, T1 and T2 became aware of C1's absence from group when group arrived to local shopping center.

Licensee retraced neighborhood walk's route while T1 and T2 remained with the other enrolled children in local shopping center. T2 also searched for C1 at local shopping center. At approximately 10:57am, T1 contacted emergency services phone number to report C1’s absence from group. Per licensee, T1 was informed C1 had been found at a different, local preschool, not related to licensee’s family child care home. Preschool C1 was found at was approximately 5 minutes walking distance from local shopping center. C1 was unharmed and brought back to licensee’s care by SFPD. Licensee stated entire incident was 12 minutes long.

(Continue Report on Page 2...)
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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 3


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: FORDE, KELLY E.
FACILITY NUMBER: 384001605
VISIT DATE: 05/12/2022
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
26
27
28
29
30
31
32
(Continued, Page 2...)
Authorized representatives of C1 were informed of incident by licensee. Licensee reported incident to CCLD on May 4, 2022. Conferences with C1's authorized representatives were held May 4, 2022, May 5, 2022 and May 11, 2022. On date of LPA's visit, C1 was attending licensee's family child care home.

Based on interviews, record review and licensee self-reporting, a child was left unattended and unsupervised by licensee and/or licensee’s staff, therefore an immediate civil penalty has been cited under H&S 1597.58 (c)(2). Please refer to 809D for more information.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall results in an immediate civil penalty of $100.

LPA Quimbo informed licensee, Kelly Forde, that this report dated May 12, 2022 documents one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Quimbo informed the licensee to provide a copy of this licensing report dated May 12, 2022 that documents any Type A citation to parents/guardian of all children enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the licensee, Kelly Forde.
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/12/2022 12:11 PM - It Cannot Be Edited

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: FORDE, KELLY E.
FACILITY NUMBER: 384001605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited

1
2
3
4
5
6
7
1597.58 Civil Penalties (c)(2) The department shall assess an immediate civil penalty...for any of the following serious violations...Absence of supervision, including, but not limited to, a child left unattended and a child left alone...
This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on interviews, record review and licensee self reporting incident, a child was left unattended and unsupervised by licensee and/or licensee’s staff in a public setting.
8
9
10
11
12
13
14
Office meeting to be conducted at a later date.

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: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3