<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414004132
Report Date: 08/27/2024
Date Signed: 08/27/2024 05:43:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 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
07/03/2024 and conducted by Evaluator Kassandra Medrano
COMPLAINT CONTROL NUMBER: 05-CC-20240703164018
FACILITY NAME:ALL FIVE @ BELLE HAVEN (PS)FACILITY NUMBER:
414004132
ADMINISTRATOR:CAROL THOMSENFACILITY TYPE:
850
ADDRESS:415 IVY DRIVETELEPHONE:
(650) 387-8268
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:60CENSUS: 41DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jenna and KatherineTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not meeting the needs and services for children in care
Staff innapropriatley handle children in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kassandra Medrano, conducted a subsequent site visit to the facility to deliver investigation findings. As the director is out on sabbatical LPA met with Designated Facility Representative, Katherine Lacson,and the purpose of the visit was explained.
LPA Medrano interviewed staff, management, and parents. Based on interviews, observations, as well as information gathered; it was found that the facility has not been meeting the needs of children in care as well as innapropriatley handling children in care. The allegations noted above are thus found to be SUBSTANTIATED, meaning the allegation is valid because the preponderance of the evidence standard has been met.

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 APPLICANT/PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.

This TYPE A citation page shall be posted for 30 days along with the “Notice of Site Visit.” This page shall be provided to all parents of children currently enrolled, and any future children being enrolled for the next 12 months per AB 633 requirements.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (650) 400-9920
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 05-CC-20240703164018
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ALL FIVE @ BELLE HAVEN (PS)
FACILITY NUMBER: 414004132
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
101223(a)(1)
1
2
3
4
5
6
7
Personal Rights (a)The licensee shall ensure that each child is accorded the following personal rights:(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Facility to conduct training on behaviors and handling children. Facility representative to send documentation of training notes as well as sign in sheets for training.
8
9
10
11
12
13
14
Based on interviews and record reviews, this requirement was not met as it was stated that staff innaporpriatley handle children in care. This poses an immediate health and safety risk to children in care.
8
9
10
11
12
13
14
Type A
09/27/2024
Section Cited
CCR
101223(a)(2)
1
2
3
4
5
6
7
Personal Rights(a)The licensee shall ensure that each child is accorded the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Facility to conduct training on inclusivity on site, Facility representative to send documentation of training notes as well as sign in sheets for training.
8
9
10
11
12
13
14
Based on interviews it was found that facility did not meet the needs of children in care. This poses a potential health and safety risk to children in care.
8
9
10
11
12
13
14
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) 266-8817
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (650) 400-9920
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2