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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210111538
Report Date: 11/28/2023
Date Signed: 11/28/2023 12:35:56 PM

Document Has Been Signed on 11/28/2023 12:35 PM - 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:C.A.M (CFS) HAMILTON (SA)FACILITY NUMBER:
210111538
ADMINISTRATOR:LOMBARDI KELSEYFACILITY TYPE:
840
ADDRESS:5520 NAVE DRIVETELEPHONE:
(415) 883-4385
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 47TOTAL ENROLLED CHILDREN: 47CENSUS: 0DATE:
11/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Alida LeonTIME COMPLETED:
12:45 PM
NARRATIVE
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On November 28, 2023, Licensing Program Analyst (LPA) Garcia made an unannounced case management visit to the child day care facility listed above and met with Site Supervisor, Alida Leon. Purpose of the visit was explained to the director. The case management visit is from a self reported incident that occurred on November 8, 2023.

LPA Garcia interviewed site supervisor, Alida Leon regarding the incident that occurred on November 8, 2023. Per Alida, there were 12 children in the school age program that day with a total of 4 teachers. One the teachers leave at 3:15 PM and the other at 4:00 PM. One child was feeling tired that day and fell asleep on the teacher's lap while doing story time. The teacher put the child in a quiet space in the room while the whole class continued their activity. When the two teachers left, the remaining teachers were reminded by the teachers leaving, that one child is sleeping and not to forget.

According to Alida, the children started lining up at 4:10 PM to go outside and at 4:15 PM was the time the remaining two teachers realized about the sleeping child in the classroom. They immediately went back to check on the child. According to Alida, one of the teachers that inadvertently left the child told the mother, who is also a teacher in the facility about the incident because she was feeling bad. The same teacher reported the incident to the site manager on November 13, 2023, coming back from the Veteran's Day Weekend. That was also when Human Resources was involved and the two teachers are put on administrative leave due to the seriousness of the incident.

Per Alida, she has implemented a training for all staff around active supervision and head count. The Human Resources is also conducting their own investigation and implement actions that may be required.

***continue to page 2****
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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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Document Has Been Signed on 11/28/2023 12:35 PM - It Cannot Be Edited


Created By: Nathan Garcia On 11/28/2023 at 11:52 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: C.A.M (CFS) HAMILTON (SA)
FACILITY NUMBER: 210111538

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2023
Section Cited
CCR
101229(a)

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101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.

This requirement is not met as evidenced by:
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Facility has implemented supervision training for all staff on November 27, 2023 through Microsoft Teams. Site supervisor will have another training for the two teachers involved today.
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A child was left sleeping and unattended in the classroom while the teachers and other children were outside which poses a potential health and safety risk to children in care.
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The facility will send a confirmation of the trainings by set due date.
Type B
12/28/2023
Section Cited
CCR101161(a)

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1011161 Limitations in Capacity
(a) A licensee shall not operate a child care center beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidence by:
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The facility will be revisited for a change of capacity and room changes once the fire inspection is granted.
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LPA has observed that the facility is operating in classroom 5 which is not part of the school age program rooms. Room 5 is currently under the the preschool license number 213001939. This poses a potential health and safety risk to children in care.
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The facility has a pending fire inspection request.
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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: C.A.M (CFS) HAMILTON (SA)
FACILITY NUMBER: 210111538
VISIT DATE: 11/28/2023
NARRATIVE
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***Page 2 continued***

The LPA also observed that under the license capacity, the school age program (210111538) operates at room 6 and the preschool program (213001939) operates at rooms 3,4,5 and 8. The facility currently utilize room 5 and 6 for their school age classroom and the incident occurred in classroom 5, which is a classroom under the preschool license number 213001939. Therefore the facility is operating beyond their license limitations. The facility has sent a request for room changes and increase capacity for the school age license #213001939 to the department and is pending approval from the fire inspector.

LPA Garcia discussed with Alida Leon the deficiencies observed in the facility and is invited for an informal office meeting due to the recent incidents that have happened in the previous months. A letter will be sent to the facility detailing the date and time of the office meeting.

Type B Violation CCR 101229 Responsibility for Providing Care and Supervision

Type B Violation CCR 101161 Limitations on Capacity

See 2nd Page for 809D Deficiency page

A copy of this report was given to the Licensee and a site visit notification must be posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview was conducted and report was reviewed with Site Supervisor, Alida Leon.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
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