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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002202
Report Date: 05/30/2024
Date Signed: 05/30/2024 09:45:27 AM

Document Has Been Signed on 05/30/2024 09:45 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FACESSF - HAYES VALLEY CDC (INFANT)FACILITY NUMBER:
384002202
ADMINISTRATOR/
DIRECTOR:		KIMBERLY WONGFACILITY TYPE:
830
ADDRESS:305 BUCHANAN STREETTELEPHONE:
(415) 552-1535
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY: 18TOTAL ENROLLED CHILDREN: 18CENSUS: 13DATE:
05/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Stephanie KuyperTIME VISIT/
INSPECTION COMPLETED:
11:02 AM
NARRATIVE
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On May 30, 2024, Licensing Program Analyst (LPAs) Sheran Lo and Zeynep Basak conducted a case management inspection and met with Director Stephanie Kuyper. Purpose of the inspection was explained. Present were Director, 5 teachers, and 13 children in care. The case management was related to the unusual incident reports that was submitted by Director which occurred at the facility on May 14, 2024.

The incident that occurred was when the director noticed a child left unsupervised in the classroom.

Discussed during the inspection was to get more information of how the incident happened and what was done to prevent it from happening again. Director discussed with the staff involved of the severity of supervising children at all times. Facility has conducted an all staff training regarding supervision, key points of communication with each other, and added an extra step for transitions.

Exit interview was conducted with Director Stephanie Kuyper. The report and Notice of Site Visit was provided. Notice of Site Visit will be posted for 30 days.


California Code of Regulations, (Title 22, Division 12, Chapter 1), are being cited on the attached LIC 809D


SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Sheran Lo
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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 05/30/2024 09:45 AM - It Cannot Be Edited


Created By: Sheran Lo On 05/30/2024 at 09:31 AM
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: FACESSF - HAYES VALLEY CDC (INFANT)
FACILITY NUMBER: 384002202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2024
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary...(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified... Supervision shall include visual observation.
This requirement is not met as evidenced by:
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Director gave staff a written document to be filed, conducted all staff training, and added extra step for transitions.
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Based on interviews, facility did not ensure to provide supervision at all times, which poses a potential Health, Safety, and Personal Rights risk to persons in care.
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POC Cleared

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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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Sheran Lo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
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