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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005020
Report Date: 08/14/2024
Date Signed: 08/14/2024 03:41:34 PM

Document Has Been Signed on 08/14/2024 03:41 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) MEADOW PARK (INF)FACILITY NUMBER:
214005020
ADMINISTRATOR/
DIRECTOR:		LOMBARDI, KELSEYFACILITY TYPE:
830
ADDRESS:5 HUTCHINS WAYTELEPHONE:
(415) 884-2004
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 5DATE:
08/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:59 PM
MET WITH:Ana PinedaTIME VISIT/
INSPECTION COMPLETED:
03:55 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 August 14, 2024, Licensing Program Analyst (LPA) Garcia made an unannounced case management visit to the child day care facility listed above and met with teacher Rosa Vazquez. Purpose of the visit was explained to the staff. The case management visit is from a self reported incident that occurred on 7/29/2024. The facility had 5 children and 3 teachers supervising the children during the visit.

The day of the incident, July 29, 2024, a staff member was cleaning in the outdoor area of the facility and found a child outdoors, unattended. According to the report, the child was brought back inside by the same staff member and the child was not harmed.

LPA Garcia spoke with Site Supervisor, Ana Pineda over the phone regarding the incident and how it occurred. According to Ana, the Human Resources are still in the process of investigating the incident and one teacher is on administrative leave. Based on the interviews and documents obtained and conducted by LPA, there was miscommunication between teachers, resulting in lack of supervision of child in care.

Type B Deficiency for care and 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 teacher, Rosa Vazquez.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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 2
Document Has Been Signed on 08/14/2024 03:41 PM - It Cannot Be Edited


Created By: Nathan Garcia On 08/14/2024 at 03:13 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) MEADOW PARK (INF)
FACILITY NUMBER: 214005020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2024
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
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 was not met as evidence
1
2
3
4
5
6
7
The facility conducted active supervision trainings with the staff members. The facility implemented head counting and double checking child care areas during transitions.
8
9
10
11
12
13
14
The child was left unattended at the outdoor area of the facility.
8
9
10
11
12
13
14
Citation issued today will also be cleared at the time of 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: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


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