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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004684
Report Date: 11/03/2023
Date Signed: 11/03/2023 12:45:54 PM

Document Has Been Signed on 11/03/2023 12:45 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:COW HOLLOW SCHOOLFACILITY NUMBER:
384004684
ADMINISTRATOR:CAMPBELL, DARCYFACILITY TYPE:
850
ADDRESS:387 MORAGA AVENUETELEPHONE:
(415) 921-2328
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94129
CAPACITY: 150TOTAL ENROLLED CHILDREN: 150CENSUS: 109DATE:
11/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Darcy Campbell & Trevor ValentinoTIME COMPLETED:
01:00 PM
NARRATIVE
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On November 03, 2023, at approximately 11:30am, Licensing Program Analyst (LPA) Ly conducted Unannounced Case Management Visit in regards to the Self Reported Incident. Purpose of visit was explained. LPA met with Chief Operating Officer Trevor Valentino and the Executive Director, Darcy Campbell.

Facility Representative reported via phone to Licensee within 24 hours known of the unusual incident and follow up with a written report (LIC624).

During today's visit, LPA and Chief Operating Officer had a tour of the facility. LPA interviewed staff and collected information in regards to the Self Reported Incident that took place around October 17 - October 18, 2023. Interviews of staff did not reveal any violation at this time.


No deficiencies were issued today under Title 22 Division 12 of the California Code of Regulations. A copy of this report was discussed and left with Executive Director whose signature on this form confirm receipt of these reports. Notice to remain posted for 30 days.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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