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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005525
Report Date: 06/19/2023
Date Signed: 06/19/2023 12:03:30 PM

Document Has Been Signed on 06/19/2023 12:03 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:NORTH BAY CHILDREN'S CENTER-HAMILTONFACILITY NUMBER:
214005525
ADMINISTRATOR:KRISTINA SISSECKFACILITY TYPE:
850
ADDRESS:5530 NAVE DRIVETELEPHONE:
(415) 883-6222
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 23TOTAL ENROLLED CHILDREN: 23CENSUS: 0DATE:
06/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Kristina SisseckTIME COMPLETED:
12:30 PM
NARRATIVE
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On 6/19/23, Licensing Program Analyst (LPA) Garcia made a scheduled case management visit to the child day care facility listed above and met with VP of Programs, Kristina Sisseck and Area Director, Nicole Porter. In conjunction with another case management visit from a self reported incident that occurred on 5/18/2023. The facility did not have any children on site during the visit.

On the day of the incident, the children were transitioning from the park to lunch time and the child was hiding in the play structure while the kids were lined up getting ready to leave. There were 3 teachers and Audra who was on the other classroom overlooking the area. The child then ran across the black top to Audra's room where he said that he was left and that when the staff from the classroom saw him running and was escorted back with his classmates. The parents of the child were informed and were thankful and the facility already went over and sent supervision policies and will be doing multiple head counts each transition per Audra.

Per Nicole, the facility has implemented multiple head counts starting from the park and doing another head count when the class arrives in the classroom. There was also a supervision plan for the children that includes charts with face to name counts and a tether is provided for all the children to hold while transitioning. There was also a meeting for all the staff reviewing the supervision policies for the children.

Type B violation was cited today under California Code of Regulations, Title 22, Division 12.

101229 Responsibility for Providing Care and Supervision

Exit interview was conducted and report was reviewed with VP of Programs, Kristina Sisseck and Area Director, Nicole Porter.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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 06/19/2023 12:03 PM - It Cannot Be Edited


Created By: Nathan Garcia On 06/19/2023 at 11:29 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: NORTH BAY CHILDREN'S CENTER-HAMILTON
FACILITY NUMBER: 214005525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2023
Section Cited
CCR
101229

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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.
(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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The facility has provided supervision policies and meeting with staff members reminding them to make multiple head counts for transitions and included charts with face to name counts and a tether is provided for all the children to hold while transitioning. The incident was self reported to the department and took proactive measure to ensure that all children are supervised.
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This requirement is not met as evidenced by record reviews and interview. The facility self reported the incident of the child being left alone in the park during transition. This posed an immediate health and safety risk to child(ren) 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: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


LIC809 (FAS) - (06/04)
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