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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004110
Report Date: 08/01/2024
Date Signed: 11/01/2024 08:33:57 AM

Document Has Been Signed on 11/01/2024 08:33 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:CREATIVE GARDENSFACILITY NUMBER:
384004110
ADMINISTRATOR/
DIRECTOR:		LAU, AGNESFACILITY TYPE:
850
ADDRESS:1429 VALENCIA STREETTELEPHONE:
(415) 577-8389
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 56TOTAL ENROLLED CHILDREN: 56CENSUS: 29DATE:
08/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Agnes LauTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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***This is an amended report from 08/01/2024***

On 8/1/2024 at 8:30AM. Licensing Program Analyst (LPA) Luis Gomez met with Caroline Erazo. Director, Agnes Lau arrived during inspection. The purpose of Case Management report is to cite deficiencies observed during inspection. LPA inspected facility for health and safety hazards.

At 12:00PM., Based on record review, interview, and observation, LPA confirmed staff member (S1) present without facility association.



LPA reminded director to ensure staff's proof of immunization and Mandated Reporter Training (AB1207) certificates are stored in facility records. Advisory Note: Technical Violations (LIC9102) were issued.

Based on today's inspection, deficiencies were observed in areas evaluated according to California Title 22, Div. 12 Chap. 1, Health and Safety, Code of Regulations and cited on 809D. Exit interview was discussed with Director, Agnes Lau, including plans for correction and evaluation report. Director’s signature of this form acknowledges the receipt of these documents.



A copy of this report and appeal rights were reviewed and provided.

This report must be made available in the facility for public review. Notice of site visit was given and must remain posted for 30 days. Director was advised any additional questions to call office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

SUPERVISORS NAME: Carol Marcroft
LICENSING EVALUATOR NAME: Cindy Interiano
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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 11/01/2024 08:34 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/01/2024 08:27 AM


Created By: Cindy Interiano On 08/01/2024 at 12:48 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CREATIVE GARDENS
FACILITY NUMBER: 384004110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/02/2024
Section Cited
CCR
101170(e)(3)

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**This is an ammended report from 08/01/24**
101170(e)(3) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility. This requirement was not met as evidence by:
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Director will ensure staff (S1) received facility association prior to presence in facility.

Enrolled families will sign LIC9224, 'Notice of A-type deficiency'.
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At 12:00PM., Based on record review, interview, and observation, LPA confirmed staff member (S1) present without facility association. This poses an immediate health and safety risk to children in care.
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Civil penalty of $100.00 issued during inspection.


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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:Carol Marcroft
LICENSING EVALUATOR NAME:Cindy Interiano
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024


LIC809 (FAS) - (06/04)
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