<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004587
Report Date: 10/13/2023
Date Signed: 10/13/2023 01:57:45 PM

Document Has Been Signed on 10/13/2023 01:57 PM - 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: 68DATE:
10/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Melanie Jacobs and Mia AcunaTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On October 13, 2023., Licensing Program Analysts (LPAs) Van and Tse conducted an announced case management in conjunction with the complaint investigation and met with the Site Director, Mia Acuna, and the Head of the school, Melanie Jacobs. The case management aimed to address the unusual incident reported to the Department on October 4, 2023. Entrance to the facility was granted. Eleven teachers were supervising 68 preschool children. The facility met the teachers/children ratio.

LPAs conducted an interview with the staff regarding an Unusual Incident Report. According to S1, a preschool child was pushed by another child while they were playing on the "hill" structure, causing C1 to fall four feet to the ground. S1 and other staff members were present at the time of the incident and promptly attended to the child. The parents were notified immediately. Based on the interviews and records reviewed, it was found that the teacher-to-children ratio was met on the day the incident occurred. It was determined that no supervision was found.

LPAs informed the Head of the school and site Director that no further action would be taken at this moment.

A copy of this report was given to the Head of the school and site Director.

An exit interview was conducted, and the report was reviewed with the Head of the school, Melanie Jacobs.

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1