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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002202
Report Date: 01/13/2025
Date Signed: 01/14/2025 08:43:44 AM

Document Has Been Signed on 01/14/2025 08:43 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: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: 15CENSUS: 13DATE:
01/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mei ChenTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 1/13/2025, Licensing Program Analyst (LPA) Zeynep Basak arrived at the facility to conduct case management inspection. The facility's director was absent and the designee (another center's director), Mei Chen arrived at 9:55 am.
The purpose of the visit was explained to the designee.
LPA was observed 8 staff and 13 children (3 infant, 10 toddlers) present during the visit.
All individuals present in the center have fingerprint clearance and the center was operating within its capacity and by the required ratio of staff to children during today's inspection.

The case management was related to the two unusual incident reports submitted by the director on 12/17/2024.

The two incidents occurred in the same day but different times. The first incident was when the teacher witnessed another teacher grabbed the child by the shoulder and shook him after child had taken a toy away from another child. The second incident was the same staff member pushing a child's head down to force to take a nap the child was already crying and did not want to take a nap.

LPA discussed during the inspection to get more information on how the incident happened and what was done to prevent it from happening again. LPA also was able to talk to director Stephanie Kuyper on the phone regarding the incident. Mei Chen stated the staff member was put administrative leave until the director and the program manager discuss the situation and make a decision. Mei Chen also stated the facility will continue to take this matter seriously and staff will be reminded of Personal Rights and given training.
See page 2.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Zeynep Basak
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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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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: FACESSF - HAYES VALLEY CDC (INFANT)
FACILITY NUMBER: 384002202
VISIT DATE: 01/13/2025
NARRATIVE
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A Type B violation will be cited on LIC 809D in accordance with Title 22 Division 12 Chapter 1 101223 Personal Rights (a)(3)

An exit interview was conducted with the designee, Mei Chen.
The report and the Notice of Site Visit were provided to be posted for 30 days.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Zeynep Basak
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2025 08:43 AM - It Cannot Be Edited


Created By: Zeynep Basak On 01/13/2025 at 11:12 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: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2025
Section Cited
CCR
101223(a)(3)

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101223 Personal Rights (a)The licensee shall ensure that each child is accorded the following personal rights: (3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

This requirement is not met by:
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They will decide on that specific staff member as she is already on administrative leave. They will also train all staff on Personal Rights.
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Based on interviews, obtained information, and record review, the facility did not comply with the section cited above which poses a potential health, safety, or personal rights risk to 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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Zeynep Basak
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


LIC809 (FAS) - (06/04)
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