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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004236
Report Date: 08/21/2019
Date Signed: 08/21/2019 05:18:58 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:BUILDING KIDZ (PS)FACILITY NUMBER:
414004236
ADMINISTRATOR:NESHEIWAT, SAMANTHAFACILITY TYPE:
850
ADDRESS:39 E. 39TH AVENUETELEPHONE:
(650) 212-5439
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:70CENSUS: 52DATE:
08/21/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Samantha Nesheiwat, Jennifer Nushwat, and Danielle PhilapilTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Marie Rodriguez made an unannounced Case Management visit to follow up on an incident reported to CCLD by phone on 8/12/19. LPA met with Assistant Director Danielle Philapil and stated purpose of visit. Executive Directors Jennifer Nushwat and Samantha Nesheiwat were notified by phone and arrived a short time later. Assistant Director provided LPA with a copy of the incident report. Original copy was faxed to CCLD office on 8/12/19. Per incident report received, Child (C1) hit, screamed at, and pinched Staff (S1) numerous times after being dropped off in the morning. LPA conducted interviews with staff, reviewed Child C1's record, and reviewed video surveillance of the incident between C1 and S1.

Based on review of video surveillance on 8/12/19, LPA observed the following: C1 is seen going up to S1 in the playground right after being dropped off and start to hit S1 unprovoked. S1 was seen tending to another child prior to the incident. For a ten minute period, C1 is seen going back and forth between screaming and hitting S1 to playing with other children in the playground. S1 is seen throughout the incident either ignoring C1's attack or trying to speak to C1 in a calm manner while C1 continued to try to hit and scream at S1. After ten minutes, C1's Parent (P1) is seen returning to the playground and trying to talk to C1 while C1 is trying to get away from parent. There is a period of one or two minutes where the actions of C1 and P1 could not be seen on video due to an awning blocking the view of the camera. P1 is then seen trying to grab and pull C1 out of the play structure after C1 hid underneath it. P1 is then seen going to S1 and appears to scream at S1 based on P1's body language for a couple of minutes. P1 also grabs S1's wrists before leaving the playground with C1. Facility will try to provide a copy of the video surveillance footage to CCLD prior to the automatic deletion of footage after 30 days. Based on review of C1's record, there have been a few recent internal incident/unusual reports written of C1 hitting and screaming at staff after being dropped off.

A police report was filed right after the incident occurred due to P1's behavior and threats made to S1 and the file number was provided to LPA. An internal investigation was conducted after the incident occurred. Executive Director Jennifer Nushwat discussed the incident with P1. C1 is no longer enrolled at the facility as of 8/13/19. A staff meeting is planned for next week to discuss the incident and training will be provided on how to handle these types of incidents in the future.

No deficiencies were cited today. This report was reviewed and discussed with Executive Directors Jennifer Nushwat and Samantha Nesheiwat. A copy of the report was provided. This report must be available in the facility for public review. Notice of site visit was observed being posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) -26-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019
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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