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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213001939
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:32:32 PM

Document Has Been Signed on 12/14/2023 04:32 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 (PS)FACILITY NUMBER:
213001939
ADMINISTRATOR:LOMBARDI KELSEYFACILITY TYPE:
850
ADDRESS:5520 NAVE DRIVETELEPHONE:
(415) 883-3791
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 80TOTAL ENROLLED CHILDREN: 80CENSUS: 29DATE:
12/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Alida LeonTIME COMPLETED:
04:45 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
On December 14, 2023, Licensing Program Analyst (LPA) Garcia made an unannounced case management visit to the child day care facility listed above and met with Site Manager, Alida Leon. Purpose of the visit was explained to the director. The case management visit is from a self reported incident that occurred on 12/6/2023. The facility had 29 children and 9 teachers in total on site.

The day of the incident, December 6, 2023, the student shared with her mother that a teacher from room 3 allegedly pushed the child's head down to the mat during nap time. The facility's Human Resources department and site leadership teams are conducting their own investigation about the incident and the teacher in question is currently on administrative leave.

LPA Garcia interviewed the site manager and gathered the written statements that she conducted with the staff members in that classroom. Based on the interviews conducted by LPA and documents obtained, children's personal rights were violated.

Type B Violation for violating child's Personal Rights.

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 Manager, Alida Leon
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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
Document Has Been Signed on 12/14/2023 04:32 PM - It Cannot Be Edited


Created By: Nathan Garcia On 12/14/2023 at 03:34 PM
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 (PS)
FACILITY NUMBER: 213001939

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2024
Section Cited
CCR
101223(a)(1)

1
2
3
4
5
6
7
101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The facility leadership and Human Resources conducted their interviews and the staff member was put on administrative leave.
8
9
10
11
12
13
14
The child's personal rights were violated when the staff member pushed the child's head down to the mat during nap time. This poses a potential health and safety risk to children in care.
8
9
10
11
12
13
14
The citation will be issued and cleared on the same visit.

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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


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