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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001816
Report Date: 10/08/2024
Date Signed: 10/08/2024 01:57:32 PM

Document Has Been Signed on 10/08/2024 01:57 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PACIFIC PRIMARY - ORANGE SUN CAMPUSFACILITY NUMBER:
384001816
ADMINISTRATOR/
DIRECTOR:		STANCIL, MADONNA-DIRECTORFACILITY TYPE:
850
ADDRESS:1501 GROVE STREETTELEPHONE:
(415) 409-1961
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY: 75TOTAL ENROLLED CHILDREN: 75CENSUS: 72DATE:
10/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Director, Madonna StancilTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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On 10/4/2024, at approximately 9:00AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced case management visit at the facility. LPA met with Director Madonna Stancil (D1) and explained the purpose of the visit. Present during the visit was D1, 21 staff, and 72 preschool age children.

The facility submitted an incident report to the Regional Office on 10/2/2024 for an incident that occurred on 9/18/2024. LPA reviewed facility records and found that the incident was not reported to the Regional Office within 24 hours via telephone call. A written report detailing any incident that threatens the physical or emotional health or safety of any child must be submitted within seven days. D1 was informed that a Type B deficiency would be cited today for not following reporting requirements by submitting a written report 14 days after the incident. Reporting requirements were discussed with D1 during the visit. D1 stated that they understood the timeline for reporting incidents.

See LIC809-D for deficiency cited and cleared today regarding reporting requirements. See LIC9102-TA for technical assistance provided regarding reporting requirements.

Appeal rights were provided and explained to D1. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director, Madonna Stancil.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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 10/08/2024 01:57 PM - It Cannot Be Edited


Created By: Jonathan Tse On 10/08/2024 at 01:19 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: PACIFIC PRIMARY - ORANGE SUN CAMPUS
FACILITY NUMBER: 384001816

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2024
Section Cited
CCR
101212(d)

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(d) Upon the occurrence... a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.

This requirement was not met as evidenced by:
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Reporting requirements were discussed with D1 during the visit. LPA clarified the the requirement to report via telephone or fax within 24 hours and the requirement to submit a written report within seven days.
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Based on record review, the Licensee did not comply with the above by not submitting a written report within seven days of an unusual incident occurring. This posed a potential risk to the health and safety of children in care.
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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:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
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