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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004402
Report Date: 05/30/2024
Date Signed: 05/30/2024 10:39:59 AM

Document Has Been Signed on 05/30/2024 10:39 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:KAI MING PMSQUARE CHILDREN'S CENTER-PSFACILITY NUMBER:
384004402
ADMINISTRATOR/
DIRECTOR:		MACH, CINDYFACILITY TYPE:
850
ADDRESS:671 CHINA BASIN STREETTELEPHONE:
(415) 387-3688
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94158
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 9DATE:
05/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:16 AM
MET WITH:Cindy MachTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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C1 = the child

On May 30, 2024 at approximately 08:25 AM, Licensing Program Analyst (LPA) Tso conducted an unannounced, case management visit. LPA met with Director, Cindy Mach, and explained the purpose of the visit. Present in the facility is director, 4 staff, and 9 children in care.

The case management visit is regarding an unusual incident that occurred on April 15, 2024. Facility self-reported incident to CCLD on April 18, 2024.

On April 16, 2024, during pick up time, the parent informed the classroom teacher that during bath time at home on April 15, 2024 night, the parent saw a few red marks on C1’s left upper chest area. When the parent of C1 asked C1 how C1 got the marks, C1 said that a teacher squeezed C1.

LPA interviewed with children and teachers and obtained the relevant information. There was no sufficient evidence to the incident found.

There were no deficiencies cited at this time under CCR, Title 22, Div. 12, Chapter 3. A copy of today’s report was given to the Director.

Notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director, Cindy Mach.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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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