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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004285
Report Date: 12/03/2024
Date Signed: 12/03/2024 11:43:15 AM

Document Has Been Signed on 12/03/2024 11:43 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:JUST KIDS PRESCHOOLFACILITY NUMBER:
384004285
ADMINISTRATOR/
DIRECTOR:		XIE, SANDYFACILITY TYPE:
850
ADDRESS:5727 GEARY BLVD.TELEPHONE:
(415) 418-6676
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 24DATE:
12/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Sandy XieTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On December 03, 2024, at approximately 08:45am, Licensing Program Analyst (LPA) Ly conducted an Unannounced Case Management Inspection at the facility due to a self reported incident. During today's visit, LPA met with facility Director Sandy Xie. There were 24 children and 5 staff including the Director present during today's visit.

During today's visit, LPA interviewed the Director regarding the self reported Unusual Incident Report. Based on interview, a hot tea tumbler was accessible at the children’s play area. A child accidentally knocked over the tumbler and spilled hot tea on child’s own body which resulted in first degree burn.

Based on interview and information collected, facility violated Title 22 regulation of having item poses danger to children accessible in the day care areas. LPA discussed protocols and policies with the Director and advised that facility will need to develop written protocols regarding dangerous items such as hot liquid must be made inaccessible to children in employee handbook to prevent future incidents. Type A deficiency is being cited today in accordance with the California Code of Regulations, Title 22, see LIC 809D.

Plans of Corrections (POC) were developed and reviewed with Director. 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. Director was advised Notice of Site Visit to remain posted for 30 days. Director also has been advised this report will be reviewed with parents. As proof of review, form LIC9224 will then be given to all current parents for signature and be kept in each child's file. For the next 12 months all parents shall also be provided information contained in this report and a copy of the LIC9224 will also be signed and placed in each child's file. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 12/03/2024 11:43 AM - It Cannot Be Edited


Created By: Winnie Ly On 12/03/2024 at 10:21 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: JUST KIDS PRESCHOOL
FACILITY NUMBER: 384004285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2024
Section Cited
CCR
101238(g)

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101238 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. This requirement was not met as evidence by:
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Director must ensure all items that pose danger to children must be made inaccessible to children in care. Proof of written protocol/policy regarding dangerous items which include hot liquid be made inaccessible to children must be submitted to Licensing by 12/10/2024.
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Based on self reported incident report, interview and record review, a hot tea tumbler was accessible at the children’s play area resulting in day-care child sustaining burn injury.
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Director shall submit the following to Licensing by 12/10/2024.

1. Staff Meeting Agenda and Staff Attendance Sheet with Signatures.
2. Revised Employee Handbook specify dangerous items including hot liquid be made inaccessible 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:Garfield Leung
LICENSING EVALUATOR NAME:Winnie Ly
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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