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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004601
Report Date: 01/09/2024
Date Signed: 01/09/2024 12:30:19 PM

Document Has Been Signed on 01/09/2024 12:30 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:SFUSD-GEORGE WASHINGTON CARVER ELEMENTARY SCHOOLFACILITY NUMBER:
384004601
ADMINISTRATOR:LEWIS, CATHERINEFACILITY TYPE:
850
ADDRESS:1360 OAKDALE AVENUETELEPHONE:
(415) 330-1540
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94124
CAPACITY: 144TOTAL ENROLLED CHILDREN: 144CENSUS: 45DATE:
01/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Kamael BurchTIME COMPLETED:
01:58 PM
NARRATIVE
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On January 9, 2024, Licensing Program Analyst (LPA) Sheran Lo conducted a case management inspection and met with Director Kamael Burch. This is regarding an unusual incident report received on 12/13/23 submitted by Director. Purpose of the inspection was explained to Director. Present were Director, 15 teachers, with 45 children in care.

Discussed during the inspection were regulations for children sign in/out each day and adult individual must be on pick up list on Emergency Card.


Exit interview was conducted with Director Kamael Burch. Report and Notice of Site Visit was provided. Notice of Site Visit will be posted for 30 days.


California Code of Regulations, (Title 22, Division 12, Chapter 1), are being cited on the attached LIC 809D
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Sheran Lo
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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 2
Document Has Been Signed on 01/09/2024 12:30 PM - It Cannot Be Edited


Created By: Sheran Lo On 01/09/2024 at 12:02 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SFUSD-GEORGE WASHINGTON CARVER ELEMENTARY SCHOOL
FACILITY NUMBER: 384004601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2024
Section Cited
CCR
101229.1(b)

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101229.1 Sign In and Sign Out (b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.

This requirement is not met as evidenced by:
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Facility sent out memos to families to ensure all adults picking up children are on the emergency card, and all staff received training from the Program Director regarding responsibility of following the policy.
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Based on interviews, facility did not ensure to have child signed out which poses a potential Health, Safety, and Personal Rights risk to persons in care.
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POC is cleared today. Memo was sent December 18, 2023 and staff received training on the same day.

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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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Sheran Lo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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