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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 384004643
Report Date: 06/05/2024
Date Signed: 06/05/2024 01:43:03 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2024 and conducted by Evaluator Man Tso
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20240503112042
FACILITY NAME:POTRERO HILL MONTESSORI SCHOOLFACILITY NUMBER:
384004643
ADMINISTRATOR:YANG, LIUFACILITY TYPE:
850
ADDRESS:1701 17TH STREETTELEPHONE:
(650) 476-3015
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94103
CAPACITY:54CENSUS: 19DATE:
06/05/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:(Jessica) Liu YangTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff did not clean child’s napping mat properly
Staff is not following child’s toileting schedule
INVESTIGATION FINDINGS:
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On June 05, 2024, at approximately 8:40 AM, Licensing Program Manager (LPM ) Leung and Licensing Program Analyst (LPA), Tso made an unannounced complaint investigation and met with the Administrative assistant, (Sam) Jie Kun Liu. (The Director, (Jessica) Yang Liu was not at the facility until approximately 10.00am). Purpose of the visit was explained. Present in the facility is Director, 6 teachers, and 19 children in the toddler classrooms. During the inspection, interviews were conducted with the Director and staff.

During the course of the investigation, interviews were conducted with staff members and relevant documents were gathered. Based on the interviews and observation, there was no sufficient evidence to prove that the allegations listed above having any licensing violations. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED.

Exit interview conducted and this report was reviewed with the Director whose signature confirm have read the report. Report must be made available for public review upon request. A copy of this report and appeal rights have been discussed and left with Director. Notice of Site Visit shall remain posted for 30 days.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Man TsoTELEPHONE: (650) 379-9021
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2024 and conducted by Evaluator Man Tso
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20240503112042

FACILITY NAME:POTRERO HILL MONTESSORI SCHOOLFACILITY NUMBER:
384004643
ADMINISTRATOR:YANG, LIUFACILITY TYPE:
850
ADDRESS:1701 17TH STREETTELEPHONE:
(650) 476-3015
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94103
CAPACITY:54CENSUS: 19DATE:
06/05/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:(Jessica) Liu YangTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
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9
Staff left child in soiled clothing.
INVESTIGATION FINDINGS:
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On June 05, 2024, at approximately 8:40 AM, Licensing Program Manager (LPM ) Leung and Licensing Program Analyst (LPA), Tso made an unannounced complaint investigation and met with the Administrative assistant, (Sam) Jie Kun Liu. (The Director, (Jessica) Yang Liu was not at the facility until approximately 10.00am). Purpose of the visit was explained. Present in the facility is Director, 6 teachers, and 19 children in the toddler classrooms. During the inspection, interviews were conducted with the Director and staff.

Based on LPA’s gathered information through observation, interviews and records reviews, the agency has investigated the complaint allegation above. The facility failed to comply with the personal care regulations. The preponderance of evidence standard has been met. The above allegation is found to be SUBSTANTIATED. A Type B violation was issued today, June 5, 2024 in accordance with the California Code of Regulations, Title 22, Division 12 & Chapter 3, citation was being cited on the attached LIC 9099D.

Exit interview conducted and a copy of this report and appeal rights were discussed and left with the Director, (Jessica) Liu Yang whose signature on this form confirms receipt of these reports. Notice of Site Visit (The Notice) was provided. The Notice is to remain posted for 30 days.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Man TsoTELEPHONE: (650) 379-9021
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 05-CC-20240503112042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: POTRERO HILL MONTESSORI SCHOOL
FACILITY NUMBER: 384004643
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2024
Section Cited
CCR
101428(b)
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101428 Personal Care Services (b)The infant shall be kept clean and dry at all times.

This requirement is not met as evidenced by:


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The Director would provide the plan of corrections to keep the children in care clean at all time on or before June 19, 2024.
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Based on interviews and available informattion, the facility did not comply with the section cited above that the facility left the child in care in soiled clothing, which poses / posed a potential health, safety, or personal rights risk to persons in care.
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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 LeungTELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Man TsoTELEPHONE: (650) 379-9021
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3