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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001399
Report Date: 12/03/2024
Date Signed: 12/04/2024 09:33:01 AM

Document Has Been Signed on 12/04/2024 09:33 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:RCSD-ADELANTE-SELBY SPANISH IMMERSION CDCFACILITY NUMBER:
414001399
ADMINISTRATOR/
DIRECTOR:		ORTIZ, AIDAFACILITY TYPE:
850
ADDRESS:170 SELBY LANETELEPHONE:
(650) 482-5957
CITY:ATHERTONSTATE: CAZIP CODE:
94027
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 26DATE:
12/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Site Supervisor, Eneida ManriquezTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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On December 2nd, 2024 at approximately 9am, Licensing Program Analyst (LPA) Tapia-Mandujano arrived at facility for a Case Management-Incident. LPA met with Site Supervisor, Eneida Manriquez. The purpose of the inspection was to discuss the Unusual Incident Report that was reported to the department.

Facility operates in two portable classrooms on Adelante Selby Lane Elementary School campus. Present in the facility during the inspection were Site Supervisor and a total of 7 staff supervising a total of 26 preschool age children. All adults are fingerprinted cleared through Redwood City School District.

The facility self-reported an incident that occurred on November 14th, 2024. The facility reported a child (C1) who got burnt on the side of the neck with a baking tray that was on the Kitchenette counter. During today's inspection, LPA interviewed the staff involved (S1) to get additional information regarding the incident. Per S1, the incident happened during transition to lunch where children were washing hands and then sitting down at the table to eat their lunch. Per S1, the staff eat their lunch with the children, and she had warmed up her food using the oven in the Kitchenette. Per S1, C1 had already washed hands and all the children on her table were sitting down on the table. Per S1, since children were already sitting down, she grabbed her food and sat down with the children.

Per S1, she heard children in the bathroom. S1 stated that she stood up from the table, removing the baking tray with her warmed food from the table and placed it on the Kitchenette counter to go supervise the children who were now in the bathroom. Per S1, there was not much space on the counter, so she placed the tray towards the edge of the counter. Per S1, C1 stood up and was walking towards S1 and passed by the counter too closely that her neck made contact with the backing tray. S1 stated that it happened so fast that she was unable to reach C1 before it happened. Per Site Supervisor, parents were notified, an incident report was written, and Director was notified.

Facility staff talked with Director and came up with a plan to ensure incidents like these are prevented in the future. Per Staff, the immediate action that was taken is that now the oven cannot be used while children are "active" and can only be used while children are sleeping. Per S1, she has not used the oven since the incident.

Due to the nature of the injury, Type B deficiency was received, and Plan of Correction was developed. Refer to LIC 809D for more details.

Deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

Notice of site visit was provided and shall be posted for 30 days from today's visit. An exit interview was conducted with Site Supervisor, Eneida Manriquez.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 12/04/2024 09:33 AM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 12/03/2024 at 12:08 PM
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: RCSD-ADELANTE-SELBY SPANISH IMMERSION CDC
FACILITY NUMBER: 414001399

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2025
Section Cited
CCR
101223(a)(2)

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101223: 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 by:
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Facility acted by making a rule on when the oven can be used.

Facility will create a sign and place it by the Stove to ensure all staff know the rule of when the oven can be used. Facility will also ensure that there is a designated area, inaccessible to children, readily available to place any hot objects.
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Based on interview and record review, the facility did not comply with the section cited above as facility self reported that C1 was injured by getting burned by an object that was placed in area accessible to children, which poses an immediate health, safety or personal rights risk to persons in care.
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Facility will also take a training regarding the importance of keeping any potential hazard inaccessible to the children.

Facility will submit the topics covered in the training as well as a statement acknowledging they understand the importance of safety measures for all staff at the facility.

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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:Marie Rodriguez
LICENSING EVALUATOR NAME:Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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