384002350-1-21-2021-05-CC-FBTQ-BXH2DF-20210121161814

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384002350
Report Date: 01/21/2021
Date Signed: 01/21/2021 04:18:22 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:	UCSF KIRKHAM CDC (PS)		FACILITY NUMBER:	384002350
ADMINISTRATOR:	NANCY TRINH COSTANTIELLO		FACILITY TYPE:	850
ADDRESS:	10 KIRKHAM STREET		TELEPHONE:	(415) 664-1217
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94143
CAPACITY:	93	CENSUS: 58	DATE:	01/21/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Nancy Costantiello		TIME COMPLETED:	04:10 PM

NARRATIVE

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Licensing Program Analyst (LPA), Farhan Bashir-Tariq conducted a case management inspection today in response to an unusual incident report that CCL received on October 30, 2020. Facility self-reported the incident. LPA spoke to director, Nancy Costantiello. This visit was conducted via phone call due to COVID-19 restrictions and director was informed that a copy of this report will be emailed to her. There were 58 children present today.

On 10/28/10., This incident resulted when S1 was responsible to supervise a group of 7 preschool children and taking a couple of them to bathroom, grabbed a child by wrist and dragged him to restroom inappropriately. This is a shared bathroom between two classrooms/cohorts. Management and executive staff responded immediately to the occurrence of this incident and S1 was put on administrative leave pending further investigation. Facility notified the parent in a timely manner. Incident was also reported to CCL following the correct protocol and within required time frame.

During the investigation of this incident, LPA reviewed incident report and written statements from staff and witnesses. LPA also interviewed director, staff and a parent regarding the incident. Based on the information available after investigation, it was determined that a violation of children’s personal rights occurred on the day. As a result of this breach, following citation is being issued.

> Type B deficiency was cited today under Title 22 Division 12 of the California Code of Regulations.

This report and rights to comment and appeal were discussed with Director. This report must be available in the facility for public review. Facility was advised for any additional questions to call Office, M-F, 8AM-5PM at 650-266-8800. For Rules and Regulations, visit the Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-Tariq	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021

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: UCSF KIRKHAM CDC (PS)	FACILITY NUMBER: 384002350
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/04/2021 Section Cited	1 2 3 4 5 6 7	101223...(a) The licensee shall ensure that each child is accorded the following personal rights: (3) ...To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by records review and interviews. Based on records review and interviews, staff failed to treat C1 in accordance to their personal rights. C1 was grabbed and dragged to restroom inappropriately. This poses a potential health and safety risk to children in care.	8 9 10 11 12 13 14	Additionally, facility shall also develop a plan/procedure to support staff and provide assistance in case of classroom emergencies. This plan needs to be communicated to staff.
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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: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-Tariq	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021

LIC809 (FAS) - (06/04)

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