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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001885
Report Date: 04/26/2019
Date Signed: 07/01/2019 02:53:16 PM

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:SFSU - CHILDREN'S CAMPUS (INFANT)FACILITY NUMBER:
384001885
ADMINISTRATOR:TOBIN-WALLIS, ANNAFACILITY TYPE:
830
ADDRESS:N. STATE DR.&LAKE MERCED BLVD.TELEPHONE:
(415) 405-4011
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:36CENSUS: 34DATE:
04/26/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Anna Tobin-WallisTIME COMPLETED:
02:45 PM
NARRATIVE
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**This is an amended report, pls. see Advisory note**


Licensing Program Analyst, LPA Yee conducted a case management inspection today. Present at the facility are 34 infants and 17 staff members. Facility personnel summary report was reviewed with the site director.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
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: SFSU - CHILDREN'S CAMPUS (INFANT)
FACILITY NUMBER: 384001885
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
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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: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2