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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002350
Report Date: 10/17/2023
Date Signed: 10/17/2023 01:52:51 PM

Document Has Been Signed on 10/17/2023 01:52 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:UCSF KIRKHAM CDC (PS)FACILITY NUMBER:
384002350
ADMINISTRATOR:CHONA ROBERTO-CHENGFACILITY TYPE:
850
ADDRESS:10 KIRKHAM STREETTELEPHONE:
(415) 664-1217
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94143
CAPACITY: 93TOTAL ENROLLED CHILDREN: 93CENSUS: 72DATE:
10/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH: Catherine Trabanino & Chona Roberto-ChengTIME COMPLETED:
02:15 PM
NARRATIVE
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On October 17, 2023, at approximately 1:00pm, Licensing Program Analyst (LPA) Ly conducted a Case Management Visit. This facility self reported an incident of a staff who handled a child in a rough manner. LPA met with Facility's Regional Manager Catherine Trabanino and Center Director Chona Roberto-Cheng. Present during today's visit were 19 staff including the Director caring for 72 children.

Per incident report submitted to CCLD, a child was handled in a rough manner. Involved staff was put on Administrative Leave. On this day, LPA observed staff is not present on site. Regional Manager and Director confirmed staff is not on site. Based on the information gathered regarding the incident, type B deficiency was cited today in accordance with the California Code of Regulations, Title 22, see LIC 809D.

During today's visit, Regional Manager submitted an agenda for facility Professional Development Day on 09/30/2023 and one of topics involved in "Positive Guidance." This deficiency is considered corrected and cleared as of today.

A copy of this report and appeal rights were discussed and left with Director whose signature on this form confirm receipt of reports. Notice of Site Visit was provided to Director. Letter of Deficiency Cleared also provided to the Director.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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 10/17/2023 01:52 PM - It Cannot Be Edited


Created By: Winnie Ly On 10/17/2023 at 01:29 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: UCSF KIRKHAM CDC (PS)
FACILITY NUMBER: 384002350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2023
Section Cited
CCR
101223(a)(1)

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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
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The Facility Representative immidiately took action by putting the involved staff on administrative leave and report incidents to appropriate agencies. Facility also hosted a Professional Developement Day and one of the training topics involved "Positive Guidance."
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This requirement is not met as evidenced by self reported incident to CCLD & UC Police Department Reports confirmed a staff handled a child in a rough manner.
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This deficiency is considered corrected and cleared as of today 10/17/2023.

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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:Garfield Leung
LICENSING EVALUATOR NAME:Winnie Ly
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
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