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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504793
Report Date: 01/26/2023
Date Signed: 01/26/2023 12:31:08 PM

Document Has Been Signed on 01/26/2023 12:31 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:TELEGRAPH HILL NEIGHBORHOOD CENTER(PS)FACILITY NUMBER:
380504793
ADMINISTRATOR:LUU, CONNIEFACILITY TYPE:
850
ADDRESS:660 LOMBARD STREETTELEPHONE:
(415) 421-6443
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94133
CAPACITY: 87TOTAL ENROLLED CHILDREN: 87CENSUS: 75DATE:
01/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sara DixonTIME COMPLETED:
12:45 PM
NARRATIVE
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On January 26, 2023 at approximately 10:00am , Licensing Program Analyst (LPA) Winnie Ly conducted an Unannounced Case Management Visit for a self reported t at the facility and met with Site Supervisor, Sara Dixon during the visit. Purpose of the inspection was explained. There were 66 preschool age children, 11 infants and 18 staff members present during the visit.


During today's visit, LPA interviewed a teacher and Site Supervisor. LPA also collected prominent document relating to the incident. Based on information collected as evidence, children's personal rights were violated. The deficiency is being cited based on the information collected in accordance with the California Code of Regulations, Title 22, see LIC 809D.


Plans of Corrections (POC) were developed and reviewed with Site Supervisor. A copy of this report and appeal rights were discussed and left with Site Supervisor whose signature on this form confirm receipt of these reports.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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 01/26/2023 12:31 PM - It Cannot Be Edited


Created By: Winnie Ly On 01/26/2023 at 12:10 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: TELEGRAPH HILL NEIGHBORHOOD CENTER(PS)
FACILITY NUMBER: 380504793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2023
Section Cited
CCR
101223(a()1)

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101223- Personal Rights. (a)The licensee shall ensure that each child is accorded the following personal rights: (1)To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by
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Facility representative will personally speak to the staff and document conversation. Facility needs to conduct training for all staff regarding Children's Rights.
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Based on information collected children's rights were violated by a staff member.
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Facility representative send proof of correction to the department by 02/06/2023.

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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:Garfield Leung
LICENSING EVALUATOR NAME:Winnie Ly
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023


LIC809 (FAS) - (06/04)
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