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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002300
Report Date: 01/27/2020
Date Signed: 01/27/2020 10:36:41 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:C5 CHILDREN'S SCHOOL-SFPUC (INF)FACILITY NUMBER:
384002300
ADMINISTRATOR:SHERAN LOFACILITY TYPE:
830
ADDRESS:525 GOLDEN GATE AVENUETELEPHONE:
(415) 703-1277
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:36CENSUS: 27DATE:
01/27/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Sheran LoTIME COMPLETED:
10:45 AM
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On January 27, 2020, at approximately 9:15am, Licensing Program Analyst (LPA) Winnie Ly conducted an Unannounced Case Management visit. Facility self reported an unusual incident that occurred on January 07, 2020 regarding a child that was left in the hallway while her teachers and peers returned into the building for lunch. LPA met with Site Director Sheran Lo. Purpose of visit was explained. Present during the visit were Site Director and 14 staff caring for 27 infants.

During this visit, LPA interviewed the Director. Per Director, child was left alone for approximately 1-2 minutes behind closed door. Director heard children coming back from outdoor activities and came down the stairs to check. Director found the child standing behind closed door. Per Director, she picked up the child and the child smiled at the Director. The child did not show any sign of distress. Per Director, she also notified the child's parent regarding the incident. Director also showed proof of staff meeting regarding transition protocol which also stated ways to monitor and track children transitioning from one activity to another. Follow this incident, Director had taken every action required to keep the children safe.


No deficiencies were issued today under Title 22 Division 12 of the Ca. Code of Regulations. A copy of this report was left with the Director whose signature on this form confirm receipt of these reports. Notice of Site Visit was posted. Notice to remain posted for 30 days. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie LyTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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