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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005607
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:49:19 PM

Document Has Been Signed on 06/20/2023 03:49 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:OLD FIREHOUSE SCHOOLFACILITY NUMBER:
214005607
ADMINISTRATOR:COHEN, ELIZABETHFACILITY TYPE:
850
ADDRESS:1510 FIFTH AVENUETELEPHONE:
(415) 419-5479
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 26TOTAL ENROLLED CHILDREN: 13CENSUS: 9DATE:
06/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Elizabeth NolascoTIME COMPLETED:
04:00 PM
NARRATIVE
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On 6/20/2023, Licensing Program Analyst (LPA) Hanson Leong, made an unannounced case management visit to the Child Daycare Facility listed above. The purpose of this visit was to follow up on an unusual incident report, which occurred on 5/16/2023.The LPA was granted entry by the Director, Elizabeth Nolasco. The LPA explained the purpose of the visit to the Director. All the individuals listed on the facility’s roster have been granted permission to work or be present in a childcare facility. The LPA observed two staff members supervising nine preschool aged children. Children's capacity and ratio requirements were observed to be in compliance.

The following Type B violation (potential health, safety, or personal rights risk to children in care) was cited for today’s visit because of the incident that occurred on 5/16/2023.

1. CCR 101223 (a)(3): (a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat...aids to physical functioning.

The Director was able to correct the incident from 5/16/2023 by terminating the employee and holding an all staff meeting regarding personal rights

The department cleared the deficiency listed above from today’s visit.

A copy of today’s report, the “Notice of Site Visit”, their appeal rights and the “Letter of Deficiency Citations Cleared” were given to Elizabeth Nolasco. A “Notice of Site Visit” must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. An exit interview was conducted, and the report was reviewed with Elizabeth Nolasco.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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 06/20/2023 03:49 PM - It Cannot Be Edited


Created By: Hanson Leong On 06/20/2023 at 03:10 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: OLD FIREHOUSE SCHOOL
FACILITY NUMBER: 214005607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2023
Section Cited
CCR
101223(a)(3)

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101223 Personal Rights. (a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat...aids to physical functioning.
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The employee that was involved with the incident on 5/16/2023 no longer works for the facility. The Director held a meeting on 6/2/2023 with all staff members regarding personal rights.
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This requirement is not met as evidenced by:
Based on interview and record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights 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:Hanson Leong
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
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