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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004601
Report Date: 05/08/2024
Date Signed: 05/08/2024 11:10:32 AM

Document Has Been Signed on 05/08/2024 11:10 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:SFUSD-GEORGE WASHINGTON CARVER ELEMENTARY SCHOOLFACILITY NUMBER:
384004601
ADMINISTRATOR/
DIRECTOR:		LEWIS, CATHERINEFACILITY TYPE:
850
ADDRESS:1360 OAKDALE AVENUETELEPHONE:
(415) 330-1540
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94124
CAPACITY: 144TOTAL ENROLLED CHILDREN: 66CENSUS: 51DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:34 AM
MET WITH:Kamael BurchTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On May 8, 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 April 30, 2024 submitted by Director. Purpose of the inspection was explained to Director. Present were Director, 13 teachers, with 51 children in care.

Discussed during the inspection were regulations for children's Personal Rights.


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: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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 05/08/2024 11:10 AM - It Cannot Be Edited


Created By: Sheran Lo On 05/08/2024 at 11:01 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: SFUSD-GEORGE WASHINGTON CARVER ELEMENTARY SCHOOL
FACILITY NUMBER: 384004601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2024
Section Cited
CCR
101223

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101223 Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights:(3) To be free from corporal or unusual punishment...
This requirement is not met as evidenced by:
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Facility conducted investigation, interviewed witnesses, put staff on leave, and will terminate staff.
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Based on investigation, Licensee did not ensure personal rights for a child which poses a potential Health, Safety, and Personal Rights risk to persons in care.
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POC Cleared

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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: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024


LIC809 (FAS) - (06/04)
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