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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002757
Report Date: 11/03/2021
Date Signed: 11/03/2021 01:24:42 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:SF TIKES ACADEMYFACILITY NUMBER:
384002757
ADMINISTRATOR:SHIMKUNAS, SARAHFACILITY TYPE:
850
ADDRESS:1218 SOUTH VAN NESS AVENUETELEPHONE:
(415) 826-8222
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:117CENSUS: 61DATE:
11/03/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Sarah ShimkunasTIME COMPLETED:
01:30 PM
NARRATIVE
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On 11/3/2021 at 9:50A.M. Licensing Program Analyst (LPA) Luis J. Gomez conducted an unannounced complaint investigation today and met with Director, Sarah Shimkunas. This Case Management report is to cite a deficiency that was observed during today's complaint inspection. LPA inspected facility with director for health and safety hazards.

At 10:15A.M., LPA observed Aide left alone with seven day-care children in the Koala classroom.

Based on today’s inspection, a deficiency was observed in the areas evacuated and cited according the Title 22 Division 12 of Ca. Code of Regulations and listed on the 809- D. An exit interview was conducted with Director and plan of correction was discussed. A copy of this report with the appeal rights was provided, and signature of this form acknowledges the receipt of these documents.

A copy of this report was reviewed and left with licensee. Notice of site visit was observed to be posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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: SF TIKES ACADEMY
FACILITY NUMBER: 384002757
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2021
Section Cited

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101216.4(a) Teacher- Child Ratio:There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below. This requirment is not met as evidenced by:
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Based on observations and interviews, LPA confirmed Koala classroom was not in proper Teacher- Child Ratio. This poses a potential health and safety risk to children in care.
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Proof of correction will be submitted to LPA via email.

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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: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021
LIC809 (FAS) - (06/04)
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