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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000829
Report Date: 12/08/2023
Date Signed: 12/08/2023 03:59:33 PM


Document Has Been Signed on 12/08/2023 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PENINSULA JEWISH COMMUNITY CENTER PRESCHOOLFACILITY NUMBER:
414000829
ADMINISTRATOR:LEVIN, STEPHANIEFACILITY TYPE:
850
ADDRESS:800 FOSTER CITY BLVD.TELEPHONE:
(650) 378-2670
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY:243CENSUS: 107DATE:
12/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Lauren NgoiTIME COMPLETED:
04:15 PM
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On December 8, 2023, at approximately 2:10pm, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an unannounced Case Management - incident inspection regarding an unusual incident report submitted to CCLD 11/22/2023. LPA met with Associate Director Lauren Ngoi and explained the purpose of the visit.

The incident was reported by a parent to the facility on November 21, 2023. Date and time when incident occurred is unknown. Facility self reported incident to the department on November 22, 2023. Incident involved a child claiming a teacher hit him. Facility called CPS and CPS referred Facility to police department. Facility called Foster city police department. Police came out to facility and conducted interviews and gathered information. Police is currently investigating incident and will report back to facility. Associate Director will email police report case # to LPA. Teacher is currently on leave and child has been moved into another classroom. LPA collected children's roster and personnel records.

Follow up investigation to be conducted. A Notice of Site Visit shall be posted for 30 days.

Exit interview conducted and report was reviewed with Associate Director, Lauren Ngoi.

SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Maria Olguin-LeonTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
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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