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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 384004643
Report Date: 07/26/2024
Date Signed: 07/26/2024 04:26:36 PM

Substantiated


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
05/29/2024 and conducted by Evaluator Man Tso
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20240529162332
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: 34DATE:
07/26/2024
UNANNOUNCEDTIME BEGAN:
03:56 PM
MET WITH:Director, (Jessica) Liu YangTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Staff did not provide adequate supervision to day care children resulting in injury.
Staff leaves day care children in soiled for extended period of time.
INVESTIGATION FINDINGS:
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On July 26, 2024, at 2.55PM, Licensing Program Analyst (LPA) Tso conducted an unannounced visit for delivery of the complaint investigation findings and met with the Director, (Jessica) Liu Yang. LPA explained the purpose of the inspection and were granted entry to the facility by the Director. Present, the Director, Assistant Director, and 9 staff are supervising 34 children.

Based on LPA’s gathered information through observation and interviews, the agency has investigated the complaint allegations above. The facility failed to comply with the personal rights, and infant care personal service regulations. The preponderance of evidence standard has been met. The above allegations were found to be SUBSTANTIATED. A Type B violation was issued today, July 26, 2024 for the Allegation, “Staff did not provide adequate supervision to day care children resulting in injury,” in accordance with the California Code of Regulations, Title 22, Division 12 & Chapter 3, citation was being cited on the attached LIC 9099D. For Allegation, “Staff leaves day care children in soiled for extended period of time”, no deficiency citation would be issued as the deficiency citation was given on other complaint reported on May 3, 2024.

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:
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
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 2
Control Number 05-CC-20240529162332
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: 07/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2024
Section Cited
CCR
101223(a)(2)
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Personal Rights (a)The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
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The Director should train the staff to ensure the Personal Rights for the children in care. Email LPA agenda and a signature of all in attendance by 8/29/2024.
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Based on observation and interviews, the facility did not comply with the section cited above for not provide adequate the supervision to the child in are resulting in injury, which pose 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.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2