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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 384002300
Report Date: 05/08/2020
Date Signed: 05/08/2020 01:27:12 PM



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
03/03/2020 and conducted by Evaluator Kassandra Medrano
COMPLAINT CONTROL NUMBER: 05-CC-20200303142538
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: 0DATE:
05/08/2020
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Director, Sheran LoTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Child left unsupervised
INVESTIGATION FINDINGS:
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On May 8th,2020 at 1:15pm, Licensing Program Analyst (LPA) Kassandra Medrano conducted an announced complaint investigation via phone call due to covid-19 and facility being closed today to deliver findings. LPA met with Director, Sheran Lo. The purpose of visit was explained to her, to deliver findings of above allegation.
During the process of the investigation, staff was interviewed and a walk through of the facility was conducted. LPA conducted an evaluation of care and supervision and review of facility records as well as staff and children's files.
During the investigation and review of records, director stated that an incident occurred on January 7th,2020 where a child was left behind during transition. Incident was reported to facility and a case management inspection was made for incident. Therefore, the above allegation has been SUBSTANTIATED. This report was reviewed with the licensee and a copy was emailed to director. Notice of Site Visit was posted and must remain for the next 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 05-CC-20200303142538
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: C5 CHILDREN'S SCHOOL-SFPUC (INF)
FACILITY NUMBER: 384002300
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2020
Section Cited
CCR
101229
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101229 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision …No child shall be left without the supervision of a teacher at any time... This requirement was not met as evidenced by:
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Director has given proof training on supervision and tracking of children. Therefore, deficiency will be cleared today.
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Based on conversations with director,Sheran Lo and documentation received by regional office. This incident did occur. Due to the facility self-reporting this incident, this poses a potential health and safety risk to the children.
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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: Kassandra MedranoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2020
LIC9099 (FAS) - (06/04)
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