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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004236
Report Date: 08/05/2021
Date Signed: 08/05/2021 04:50:18 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: 24DATE:
08/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Site Director Jennifer Nushwat,TIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Jyoti Saini conducted a case management visit today along with a complaint investigation. The Facility failed to file a report for an unusual incidents that happened at the facility involving C1 from 05/03/2021 through 06/11/2021.

> Type B deficiency was cited today under Title 22 Division 12 of the California Code of Regulations: See LIC 809D.

This report and rights to comment and appeal were discussed with site director.

***California Code of Regulations, (Title 22, Div. 12, Ch 3), are being cited on the attached LIC 809D.

Notice of site visit shall be posted for 30 days from today's visit.

Copy of this report was reviewed and will be sent to the director at jenniferm@buildingkidz.com by the close of business on 08/05/2021. Confirmation of receipt is required. This report will be kept in the facility file and will be made available for public review upon request.

Any additional questions, call CCLD Office, Monday - Friday, 8am - 5pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: BUILDING KIDZ (PS)
FACILITY NUMBER: 414004236
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2021
Section Cited

1
2
3
4
5
6
7
101212(d)(1)(C) Reporting Requirements. Any unusual incident or child absence that threatens the physical or emotional health or safety of a child shall be reported to the Department within 24 hours of the occurrence.
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on observation, interview, and record review, the facility did not ensure to submit unusual incident reports regarding biting incidents that occurred from 05/03/2021 through 06/11/2021. This poses a potential safety risk to children in care.

8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2