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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002303
Report Date: 11/19/2021
Date Signed: 11/19/2021 03:25:43 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:FRIENDS OF POTRERO HILL NURSERY SCHOOLFACILITY NUMBER:
384002303
ADMINISTRATOR:LEICHT, MONICAFACILITY TYPE:
850
ADDRESS:1060-A TENNESSEE STREETTELEPHONE:
(415) 864-5464
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94107
CAPACITY:30CENSUS: 11DATE:
11/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Director, Monica LeichtTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Jyoti Saini conducted a case management visit today along with a complaint investigation. In the course of conducting the investigation, LPA inspected the facility and observed violation of Title 22 and Health and Safety Code. At 9:47am, LPA observed an uncleared individual supervising the children. This poses an immediate health and safety risk to children in care.

***California Code of Regulations, (Title 22, Div. 12, Ch 3), are being cited on the attached LIC 809D.


"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS. LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.

An exit interview was conducted. Appeal rights were given and explained to the Director Monica Leicht. Copy of this report was reviewed and will be sent to the director at email address monicaleicht@gmail.com by the close of business on 11/19/2021. Confirmation of receipt is required.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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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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: FRIENDS OF POTRERO HILL NURSERY SCHOOL
FACILITY NUMBER: 384002303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2021
Section Cited

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Criminal Record Clearance(a) The Department shall conduct a criminal record review of all persons specified in Health and Safety Code Section 1596.871(b). The Department has the authority to approve or deny employment, or presence in the facility, based on the results of this review.
This requirement was not met as evidenced by:
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Based on observations and record review the facility was found to have an uncleared indvidual on staff since Feb 2020. This poses an immediate health and safety risk to children in care.
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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: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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