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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210104612
Report Date: 05/20/2024
Date Signed: 05/20/2024 09:58:26 AM

Document Has Been Signed on 05/20/2024 09:58 AM - 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:KUMARA DAY SCHOOLFACILITY NUMBER:
210104612
ADMINISTRATOR/
DIRECTOR:		ROSARIO MARTEL KNUTSONFACILITY TYPE:
850
ADDRESS:540 MARIN AVENUETELEPHONE:
(415) 388-5437
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY: 50TOTAL ENROLLED CHILDREN: 34CENSUS: 25DATE:
05/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Director, Rosario KnutsonTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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
On 5/20/2024, at approximately 9:00AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced case management visit regarding a self-reported incident at the facility. LPA met with Director, Rosario Knutson (D1). LPA explained the purpose of the visit. Present during the visit was D1, six staff members, and 25 preschool age children. The facility is in compliance with staffing and ratio requirements on this day.

On 5/6/2024, D1 self-reported an incident where a child was left without supervision in a classroom for about eight minutes. Per D1, the child was sitting in the classroom until a teacher brought them back into the main group. The child's parents were notified and the incident reported to the Regional Office on the same day.

On 5/7/2024, D1 submitted a written Unusual Incident Report (LIC624B) to the Regional Office.

During today's visit on 5/20/2024, LPA discussed reporting requirements and actions taken by the facility with D1. Per D1, the incident was discussed with all teachers and the facility now has a policy where head counts of children are conducted at least twice upon transition to another room. Teachers will conduct head counts before and after transitioning to a different room, and a physical sweep of rooms will be conducted before completing transitions. Additionally, D1 stated that classroom doors will be closed once head counts have been completed so that children will not be able to leave a teacher's supervision without them knowing.

Based on interview with D1 and record review of the incident report, LPA found that the facility had followed reporting requirements and appropriately addressed the incident with staff to ensure that similar incidents do not occur. New policies and routines have been implemented so that staff are ensuring that there is proper supervision of children in care. LPA informed D1 that a deficiency regarding supervision of children shall be cited today due to the self-reported incident. D1 stated that they understood.
Continued on Page Two
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: KUMARA DAY SCHOOL
FACILITY NUMBER: 210104612
VISIT DATE: 05/20/2024
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
26
27
28
29
30
31
32
Page Two
A Type B deficiency shall be cited during today's visit on 5/20/2024 regarding supervision of children. A plan of correction was discussed with D1. See LIC809-D for deficiency cited today.

A notice of site visit was given and must remain posted for 30 days. Appeal rights were provided and explained.

Exit interview conducted and report was reviewed with facility representative, Rosario Knutson.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 05/20/2024 09:58 AM - It Cannot Be Edited


Created By: Jonathan Tse On 05/20/2024 at 09:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: KUMARA DAY SCHOOL
FACILITY NUMBER: 210104612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision
No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
D1 shall submit a meeting agenda that contains topics pertaining to the supervision of children, head counts of children in care, and steps taken to ensure that children are always supervised. This meeting agenda shall be signed by all teachers and submitted to LPA via email by 5/31/2024.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the above by having one child without visual supervision by a teacher, which posed a potential health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

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:Ali Zebila
LICENSING EVALUATOR NAME:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3