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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 380504776
Report Date: 07/02/2024
Date Signed: 07/02/2024 11:41:42 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/15/2024 and conducted by Evaluator Jonathan Tse
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20240415093501
FACILITY NAME:NIHONMACHI LITTLE FRIENDS SUTTER SITEFACILITY NUMBER:
380504776
ADMINISTRATOR:INAMASU, CATHYFACILITY TYPE:
850
ADDRESS:1830 SUTTER STREETTELEPHONE:
(415) 922-4060
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:91CENSUS: 23DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Site Supervisor, Naomi MiuraTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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-Staff did not provide adequate supervision resulting in day care child sustaining a fracture.
-Staff did not provide an incident report to responsible party or CCL.
INVESTIGATION FINDINGS:
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On 7/2/2024, at approximately 10:00AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced complaint visit to Nihonmachi Little Friends Sutter Site. LPA met with Site Supervisor, Naomi Miura (D1), and explained the purpose of the visit. Present during the visit was D1, six staff and 23 preschool-age children.

The Investigation Bureau investigated the allegation of “Staff did not provide adequate supervision resulting in day care child sustaining a fracture”.

The IB investigator conducted interviews with facility staff, random selection of enrolled children, random selection of enrolled children’s authorized representatives, and reviewed pertinent documentation.

Based on IB’s observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the allegation that “Staff did not provide adequate supervision resulting in day care child sustaining a fracture” is found to be SUBSTANTIATED.
(Report continued on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 05-CC-20240415093501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: NIHONMACHI LITTLE FRIENDS SUTTER SITE
FACILITY NUMBER: 380504776
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2024
Section Cited
HSC
1596.99(c)(1)
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The department shall assess an immediate civil penalty...for any of the following serious violations...Any violation that the department determines resulted in the injury or illness of a child.
This requirement was not met as evidenced by:
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LPA observed children in the outdoor play area to be under close supervision during the visit. Per D1, staff have been providing close supervision during block play.
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Based on observations, interviews, and record reviews, facility staff did not provide adequate supervision which resulted in a daycare child sustaining a fracture. This poses an immediate health, safety, or personal rights risk to persons in care.
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This deficiency shall be cited and cleared on this day.
Type B
07/09/2024
Section Cited
CCR
101212(d)
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(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department...within the Department's next working day and during its normal business hours...
This requirement was not met as evidenced by:
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LPA reviewed reporting requirements with D1 during the visit. D1 understands the requirement to call and report an incident within 24 hours and to submit a written report within 7 days. D1 shall conduct a staff training regarding reporting requirements
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Based on record review, facility staff did not report an incident where a child fell to the responsible party or to CCLD within 24 hours of the incident by telephone, or within seven days by written report. This poses a potential health, safety, or personal rights risk to persons in care.
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D1 shall submit a meeting memo that is signed by all staff by set due date of 7/9/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 05-CC-20240415093501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: NIHONMACHI LITTLE FRIENDS SUTTER SITE
FACILITY NUMBER: 380504776
VISIT DATE: 07/02/2024
NARRATIVE
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(LIC9099C, Page Two)
California Health and Safety Code is being cited. An immediate civil penalty is being issued on today’s date. Please refer to LIC9099-D and LIC421IM for more information.

During today’s visit, LPA conducted staff interviews and site observations. LPA conducted a file review of the facility’s file and did not observe documentation of incident reports submitted to the Regional Office concerning the incident.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the allegation that “Staff did not provide an incident report to responsible party or CCL” is found to be SUBSTANTIATED.

See LIC9099-D for deficiency cited today.

LPA Tse informed facility representative Naomi Miura that this report dated 7/2/2024 documents one Type A citation which shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.

Also, LPA Tse informed the facility representative to provide a copy of this licensing report dated 7/2/2024 that documents any Type A citations 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.

Appeal rights were provided and explained. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Naomi Miura.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3