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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005617
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:39:12 PM

Document Has Been Signed on 02/20/2025 03:39 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:GROVE PRESCHOOL AT KOL SHOFAR, THEFACILITY NUMBER:
214005617
ADMINISTRATOR/
DIRECTOR:		BARBONI, KATHERINEFACILITY TYPE:
850
ADDRESS:215 BLACKFIELD DRIVETELEPHONE:
(415) 388-1818
CITY:TIBURONSTATE: CAZIP CODE:
94920
CAPACITY: 105TOTAL ENROLLED CHILDREN: 105CENSUS: 44DATE:
02/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:44 PM
MET WITH:Liza Monge/Gordon GladstoneTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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On February 20, 2025, Licensing Program Analysts (LPAs) Garcia and Krenn made an unannounced case management visit to the child day care facility listed above and met with assistant director, Liza Monge. Purpose of the visit was explained to Lisa. The case management visit is from a self reported incident on 1/31/25 that occurred on 1/29/2025. The facility had 44 children and 11 teachers supervising the children in five rooms during the visit.

On the day of the incident, January 29, 2025, a child was found by his parents in the parking lot during pick up time. Per incident report, the child walked out of the play yard unnoticed and was able to open the gate during the after-school program and the child was unharmed.
LPAs Garcia and Krenn interviewed Liza regarding the incident and were shown and explained how the child was able to walk away from the facility. The assistant director, Liza also shared the different protocols they've placed and trainings that staff attended to prevent a similar incident from occurring.

Based on the interview conducted by LPAs, there was lack of supervision at the moment of the incident.

Type A Deficiency issued for lack of supervision and Technical Violation for reporting requirements.

LPAs Garcia and Krenn informed licensee facility representative, Liza Monge that this report dated 2/20/2025 document 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPAs Garcia and Krenn informed the facility representative to provide a copy of this licensing report dated 2/20/2025 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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 Assistant Director, Liza Monge.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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 02/20/2025 03:39 PM - It Cannot Be Edited


Created By: Nathan Garcia On 02/20/2025 at 03:05 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: GROVE PRESCHOOL AT KOL SHOFAR, THE
FACILITY NUMBER: 214005617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/21/2025
Section Cited
CCR
101229(a)(1)

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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.

This requirement was not met as evidenced by:
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The facility implemented safety protocols such as extending hours for their security guard outside the gate, a cover will be installed on the exit door gate more inaccessible to children and ADA/fire department compliant, and sent reminders for all parents to secure the environment for all children.
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Based on the staff interview and pertinent documents collected during the visit.
This poses an immediate health, safety, or personal rights risk to persons in care.
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The deficiency cited today during the visit will be cleared.

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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: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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