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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004457
Report Date: 11/06/2019
Date Signed: 11/06/2019 01:42:48 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:2ND GENERATION CABOT (SA)FACILITY NUMBER:
414004457
ADMINISTRATOR:ALCANTARA, RACHYLFACILITY TYPE:
840
ADDRESS:342 ALLERTON AVETELEPHONE:
(650) 225-3666
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:40CENSUS: DATE:
11/06/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Rachyl Alcantara, Chrissy GuminaTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Andrea Medlin met with director and staff for this case management visit. Purpose of the visit is due to a self reported unusual incident. On 7/29/19, a child (C1) was playing in the outside courtyard. C1 was playing tag with another child; C1 slipped on the grass and his knee landed on a manhole lid. Staff applied first aid treatment; parent's were called and made aware of incident and were already in route to pick up. Parent's brought child to the doctor where it was determined child sustained injury resulting in stitches to the knee.

This appear to have been an isolated incident and an accident. LPA inspected the area where incident happened; no apparent health and safety hazards observed. Facility has since covered the manhole with elevated padding to make more visible.

This report is reviewed with director and a copy of this report must be made available for public review upon request.

Notice of site visit posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2019
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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