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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210111538
Report Date: 05/30/2024
Date Signed: 05/30/2024 12:21:02 PM

Document Has Been Signed on 05/30/2024 12:21 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/
DIRECTOR:		ALIDA LEONFACILITY TYPE:
840
ADDRESS:5520 NAVE DRIVETELEPHONE:
(415) 883-5232
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 0DATE:
05/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Bantuwan VamnutjindaTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On May 30, 2024, Licensing Program Analyst (LPA) Garcia made an unannounced case management visit to the child day care facility listed above and met with Site Supervisor, Bantuwan Vamnutjinda. Purpose of the visit was explained to staff. The case management visit is from a self reported incident that occurred on 5/15/2024. The facility had no children present in the school age program during the visit.

The day of the incident, May 15, 2024, the facility reported that a child ran out of the classroom during pick up time, without a staff member.

LPA Garcia interviewed the 2 staff members that observed the incident during the visit.

Based on the interviews conducted by LPA, children's personal rights were violated.

Type B Violation for child left without supervision.

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, Bantuwan Vamnutjinda.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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 05/30/2024 12:21 PM - It Cannot Be Edited


Created By: Nathan Garcia On 05/30/2024 at 11:41 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: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2024
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).

This requirement is not met as evidenced by:
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The facility will conduct active supervision training and go review child's personal rights and implement protocols to prevent this incident from occuring. Proof will be sent to LPA by set due date.
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A child was able to run out of the classroom when another parent was picking up their child which poses a potential health and safety risk to children in care.
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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: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
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