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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380505534
Report Date: 05/21/2025
Date Signed: 05/21/2025 11:37:59 AM

Document Has Been Signed on 05/21/2025 11:37 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:FAMILY DEVELOPMENTAL CENTER (INFANT)FACILITY NUMBER:
380505534
ADMINISTRATOR/
DIRECTOR:		BELL, EBONYFACILITY TYPE:
830
ADDRESS:2730 BRYANT STREETTELEPHONE:
(415) 282-1090
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 95TOTAL ENROLLED CHILDREN: 95CENSUS: 64DATE:
05/21/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Director, Dee LeeTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On May 21, 2025 at approximately 9:30am, Licensing Program Analysts (LPA) Melissa Zaragoza conducted an unannounced, case management visit to Family Developmental Center (Infant). LPA met with director, Dee Lee, and explained the purpose of the visit. Present during LPA's visit included 27 teaching staff and 64 children present. Facility is operating within capacity limits and ratio during LPA's visit. Teaching staff present have fingerprint clearance on file. Childcare centers hours of operation are Monday through Friday, from 7:30am to 4:30pm.

LPA conducted a visit in regard to an unusual incident's report that was reported to the department. The unusual incident was reported on March 15, 2025. The incident involves Child C1, Mother of C1, and staff member. On May 13, 2025, at around 11:58 am, pick up time. Mother of C1 picked up C1 (signed out), walked to the front desk, and paused to speak with a staff member. While mother was talking, C1 got to the water dispenser, managed to unlock the dispenser, and burned their left hand. Per director, when hot water came in contact with C1's skin, C1 began to cry, and were shaking their hand. Per director, C1’s hand got red and swollen, and C1 got a blister. Per director, the nurse ran C1’s hand under cold water, for 15 minutes. Per director, mother of C1 was advised to take C1 to urgent care for an emergency.

Per director, C1’s mother took them home. C1 missed school for some days but has returned as of today’s date, 05/21/2025. Per director, facility contacted mother of C1, and asked how C1 was doing, and the degree of the burn. Per director, mother of C1 reported they did not take C1 to urgent care for emergency because they have a friend who is a Registered Nurse, and they provided at home care. Per director, mother of C1 stated C1 is recovered, feeling better, and has no restrictions.

Per director, they have a staff training, Friday, May 23rd, and they will provide a Health and Safety Training. Per director, they will inform staff about the incident and will communicate with the team regarding the usage of the water dispenser. Per director, staff will be informed if they want to use hot water, they must get it from the staff lounge, and drink it in the staff lounge. LPA conducted a walk-through inspection to the water dispensers located at the facility, and observed children to have no access to hot water.

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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Melissa Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: FAMILY DEVELOPMENTAL CENTER (INFANT)
FACILITY NUMBER: 380505534
VISIT DATE: 05/21/2025
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A copy of this report, and the “Notice of Site Visit,” were given to the director.

A “Notice of Site Visit” must remain posted for 30 days.

An exit interview was conducted, and the report was reviewed with facility representatives, Dee Lee.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Melissa Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC809 (FAS) - (06/04)
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