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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004587
Report Date: 09/26/2023
Date Signed: 09/26/2023 11:01:03 AM

Document Has Been Signed on 09/26/2023 11:01 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:MISSION MONTESSORI (PS)FACILITY NUMBER:
384004587
ADMINISTRATOR:DOMINGO, ROCHELLEFACILITY TYPE:
850
ADDRESS:50 FELL STREETTELEPHONE:
(415) 805-8315
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 72DATE:
09/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melanie Jacobs and Mia AcunaTIME COMPLETED:
11:30 AM
NARRATIVE
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During an unannounced inspection on September 26, 2023, Licensing Program Analyst (LPA) Van met with Melanie Jacobs, the Head of the School, and new Site Director, Mia Acuna to follow up on an unusual incident and discuss preventative measures to ensure the safety and well-being of all children at the Center. The Facility self-reported an incident on September 20, 2023, where a child (C1) had left the group and was found in the elementary children’s bathroom. The Head of School explained that the incident occurred during outside recreation and was unclear when C1 left the group. After the headcount, staff noticed that C1 was missing, and C1 was later found in the bathroom designated for elementary children.

Based on the interview and the incident report received on September 20, 2023, regarding the above incident, it was found that supervision was absent when the child left the group without the teacher's knowledge. A Type "A" violation was issued today. The Facility is advised to provide a copy of the Evaluation Report and the Type "A" Deficiency cited to the parents and guardians of children currently enrolled and parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files. This report will be maintained in the facility file and made available for public review three years after the thirty-day posting requirement has been met. Today's report, September 26, 2023, appeal rights, and notice of the site were provided to the Head of the school. LPA informed the Head of the school that the site visit notice and deficiency page must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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 09/26/2023 11:01 AM - It Cannot Be Edited


Created By: Brendon Van On 09/26/2023 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: MISSION MONTESSORI (PS)
FACILITY NUMBER: 384004587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2023
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision...children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1).
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Immediate action was taken to correct this incident. On the same day, the Head of school had all staff training on supervision, accountability, scan & name, and face check. Training materials were provided to LPA during the visit.


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This requirement is not met, as evidenced by the interview and facility incident report. The staff failed to provide adequate supervision, which allowed C1 to leave the group without the staff's knowledge. This poses an immediate health and safety risk to children in care.
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A follow-up Informal Meeting is to be scheduled for a later date.

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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:Brendon Van
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
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