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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001291
Report Date: 10/12/2021
Date Signed: 10/12/2021 02:33:20 PM

Document Has Been Signed on 10/12/2021 02:33 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:KAI MING HEAD START-GEARY CENTERFACILITY NUMBER:
384001291
ADMINISTRATOR:CHA, JEE YOUNGFACILITY TYPE:
850
ADDRESS:6221 GEARY BLVD.TELEPHONE:
(415) 387-3133
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY: 49TOTAL ENROLLED CHILDREN: 49CENSUS: 29DATE:
10/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jee Young ChaTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mok conducted an unannounced inspection for an unusual incident on 9/22/21. LPA met with the Site Director, Jee Young Cha,, Reginal Managers, Mei Hua Fu, and Ellen Peterson Allen and explained the purpose of the inspection to them. There were 17 preschooler & 14 Toddlers with 15 staff present. The facility submitted an unusual incident report to CCL on 9/27/21, a child who walked out of the facility by himself without care and supervision from any facility's staff during pick-up time on 9/22/21. The child was discovered walking down the street by one of the parents under 5 minutes. The parent contacted the family advocate who brought the child back to the center.

See the next page of the deficiency that was cited during the inspection.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Cindy Mok
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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 10/12/2021 02:33 PM - It Cannot Be Edited


Created By: Cindy Mok On 10/11/2021 at 01:14 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: KAI MING HEAD START-GEARY CENTER
FACILITY NUMBER: 384001291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2021
Section Cited
HSC
1596.99(c)(3)

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ยง1596.99(c)(3) Levy of civil penalty in addition to suspension, temporary suspension, or revocation; amounts; regulations setting forth appeal procedures for deficiencies (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation, for any of the following serious violations:
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The facility created an action plan to avoid the same incident happens again. The facility also form the staff meeting about it,. LPA obtained the copies of the action plan and staff meeting material during inspection. The deficiency was cleared during the inspection.

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(3) Absence of supervision, including, but not limited to, a child left unattended, and supervision of a child by a person under 18 years of age.This requirement was not met as evidenced by based upon the report, a child who walked out of the facility by himself without care and supervision from any facility's staff during pick-up time on 9/22/21. The child was discovered walking down the street by one of the parents under 5 minutes. This poses an immediate safety risk to children in care.
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Civil penalty was issued. An office meeting may be scheduled.

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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:Ali Zebila
LICENSING EVALUATOR NAME:Cindy Mok
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021


LIC809 (FAS) - (06/04)
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