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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002514
Report Date: 03/01/2024
Date Signed: 03/01/2024 11:12:11 AM

Document Has Been Signed on 03/01/2024 11:12 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:SFUSD-COMMODORE STOCKTON EARLY ED SCHOOL (PS)FACILITY NUMBER:
384002514
ADMINISTRATOR:YU, JENNYFACILITY TYPE:
850
ADDRESS:1 TRENTON ST., RMS 1,2,3,&4TELEPHONE:
(415) 291-7932
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94108
CAPACITY: 88TOTAL ENROLLED CHILDREN: 88CENSUS: 57DATE:
03/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Jenny Yu TIME COMPLETED:
11:30 AM
NARRATIVE
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On March 01, 2024 at approximately 10:05am, Licensing Program Analyst (LPA) Ly conducted an Unannounced Case Management Visit for a self reported Unusual Incident that was reported to the department on 02/16/2024 and met with Principal, Jenny Yu during the visit. Purpose of the inspection was explained. There were 10 staff caring for 57 children during the visit.

During today's visit, LPA interviewed the Principal to obtain detail information into the Unusual Incident. Based on information collected, a child was left in the children's restroom alone for an approximate 1 minute until the staff came back for child. Child's parent was notified of the incident. Since the incident, Principal had conducted staff meeting to remind staff regarding 100% supervision of children at all time. In addition, involved staff was subjected to a written reprimand for the lack of supervision.

This self reported incident is deemed as the lack of supervision. Staff left a child in the restroom poses a potential health and safety risk to persons in care. Type B violation has been issued on this day in accordance with the California Code of Regulations, Title 22, see LIC 809D.

A copy of this report and appeal rights were discussed and left with Principal whose signature on this form confirm receipt of these reports. Notice of Site Visit was posted. Notice to remain posted for 30 days.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
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 03/01/2024 11:12 AM - It Cannot Be Edited


Created By: Winnie Ly On 03/01/2024 at 10:30 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: SFUSD-COMMODORE STOCKTON EARLY ED SCHOOL (PS)
FACILITY NUMBER: 384002514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).
This requirement is not met as evidenced by:
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Prinicipal submitted proof of conducting a meeting with involved staff.
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Based on self reported unusual incident and detail information collected during visit, staff left a child in the restroom for an approximate 1 minute poses a potential health and safety risk to persons in care.
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This deficiency is considered corrected and cleared as of today.

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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: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024


LIC809 (FAS) - (06/04)
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