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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004798
Report Date: 08/26/2024
Date Signed: 08/26/2024 11:19:50 AM

Document Has Been Signed on 08/26/2024 11:19 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:C5 SF PERMIT BUILDING CENTERFACILITY NUMBER:
384004798
ADMINISTRATOR/
DIRECTOR:		LOYOLA-SALCEDO, MARYFACILITY TYPE:
850
ADDRESS:49 SOUTH VAN NESS AVENUE #310TELEPHONE:
(415) 341-6723
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94103
CAPACITY: 54TOTAL ENROLLED CHILDREN: 11CENSUS: 5DATE:
08/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Asako McGeeTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
NARRATIVE
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C1 = Child 1
S1 = Staff 1 S2 = Staff 2

On August 26, 2024 at approximately 10:00 AM, Licensing Program Analyst (LPA) Tso conducted an unannounced, case management visit. LPA met with Director, Asako McGee, and explained the purpose of the visit. Present in the facility is 2 directors, 3 staff, and 5 children in care.

The case management visit is regarding an unusual incident that occurred on July 23, 2024. Facility self-reported incident to CCLD on August 2, 2024.

On July 23, 2024, at approximately 5:00pm. S1 transitioned three children back to classroom from the outdoor space, despite S2 asked S1 not to do so as S2 was temporarily tending a child indoor. After S2 found S1 with 2 children and 2 parents in a classroom. S1, S2 and a parent saw C1 was tapping the closed glass door from outside alone. S1 opened the door immediately.

According to the interview and incident report, C1 was left outdoors unattained. This posed a potential risk to the health, safety or personal rights risks to the person in care. A Type B citation is issued for this deficiency this day. (See LIC809 D). The Director stated that the facility conducted a safety and supervision training for all staff on 8/14/2024. The deficiency citation was cleared today (8/26/24).

An exit interview was conducted with the Director, Asako McGee, and a plan of correction was discussed. A copy of this report with the appeal rights was discussed and provided, and the signature of this form acknowledges the receipt of these documents. A notice of site visit was given to the Director and must remain posted for 30 days.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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 08/26/2024 11:19 AM - It Cannot Be Edited


Created By: Man Tso On 08/26/2024 at 11:06 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: C5 SF PERMIT BUILDING CENTER
FACILITY NUMBER: 384004798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2024
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.

This requirement was not met as evidenced by:
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Director agrees to train staff on proper supervision and email LPA agenda and a signature of all in attendance by 9/10/2024. The Director stated that the facility conducted a safety and supervision training for all staff on 8/14/2024. The deficiency citation was cleared on today (8/26/24) visit.
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Based on interview and Incident report, staff left a child alone without supervision in the outdoor area, which poses/posed a potential risk to 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 Leung
LICENSING EVALUATOR NAME:Man Tso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
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