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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500308
Report Date: 12/16/2024
Date Signed: 12/16/2024 11:38:38 AM

Document Has Been Signed on 12/16/2024 11:38 AM - 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HOLY FAMILY DAY HOMEFACILITY NUMBER:
380500308
ADMINISTRATOR/
DIRECTOR:		POOYAN, SETAREHFACILITY TYPE:
850
ADDRESS:299 DOLORES STREETTELEPHONE:
(415) 861-5361
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94103
CAPACITY: 150TOTAL ENROLLED CHILDREN: 117CENSUS: 86DATE:
12/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:41 AM
MET WITH:Setareh Pooyan TIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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C1 = Child 1

On December 16, 2024 at approximately 9:40 AM, Licensing Program Analyst (LPA) Tso conducted an unannounced, case management visit. LPA met with Program Director, Setareh Pooyan and explained the purpose of the visit. Present in the facility is the Director, 28 staff, and 86 children in care.

The case management visit is regarding an unusual incident that occurred on November 06, 2024. Facility self-reported incident to CCLD on November 12, 2024.

On November 06, 2024, during the transition from outside to inside, the child (C1) was left in the secured toddler yard for seconds. Another teacher from different classroom saw the child immediately and took C1 to the classroom.

LPA interviewed with the Program Director, teacher, and observation. There was no evidence to the incident of lack of supervision as LPA obtained the information that C1 was still under supervision.

There were no deficiencies cited at this time under CCR, Title 22, Div. 12, Chapter 3. A copy of today’s report was given to the Director.

Notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Program Director, Setareh Pooyan.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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