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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504793
Report Date: 03/26/2024
Date Signed: 03/26/2024 03:36:45 PM

Document Has Been Signed on 03/26/2024 03:36 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: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: 86DATE:
03/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sara DixonTIME COMPLETED:
04:00 PM
NARRATIVE
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On March 26, 2024 at approximately 2:00pm, Licensing Program Analyst (LPA) Ly conducted an Unannounced Case Management Visit for a self reported incident taken place in the facility's gymnasium. LPA met with Site Supervisor, Sara Dixon during the visit. Purpose of the inspection was explained. There were 86 preschool age children, 26 staff members including the Site Supervisor and the Enrollment Specialist present during the visit.


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


Since incident was reported to the Site Supervisor and Site Director, the administrative team have take immediate action by interviewing witnesses and involved staff. Plan of Action as Plan of Corrections (POC) was developed for involved staff to follow. Facility Representative will submit the plan of action as plan of correction to LPA.

A copy of this report and was discussed and left with Site Supervisor whose signature on this form confirmed receipt of the report.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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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Document Has Been Signed on 03/26/2024 03:36 PM - It Cannot Be Edited


Created By: Winnie Ly On 03/26/2024 at 02:10 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: 03/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2024
Section Cited
CCR
101223

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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 Administrators have develop a plan of action for the involved staff.
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Based on information collected children's rights were violated by a staff member.
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Facility representative will send plan of action to the department by 04/09/2024.

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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: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024


LIC809 (FAS) - (06/04)
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