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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414002946
Report Date: 11/08/2023
Date Signed: 11/08/2023 01:09:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 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
10/09/2023 and conducted by Evaluator Andrea Medlin
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20231009150206
FACILITY NAME:TRINITY LUTHERAN PRESCHOOLFACILITY NUMBER:
414002946
ADMINISTRATOR:EYVAZOV, JAMFACILITY TYPE:
850
ADDRESS:1505 SHERMAN AVENUETELEPHONE:
(650) 580-2349
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:28CENSUS: 17DATE:
11/08/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jam EyvazovTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Staff failed to keep facility free of fleas and dead raccoons.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Andrea Medlin met with facility representative for this conclusionary complaint investigation. Purpose of visit explained. There are 17 children present. The facility was previously having a problem with rodents underneath facililty area which caused fleas to come inside preschool areas resulting in some children getting flea bites. Exterminator's were called and have fumugated the areas several times and the dead animals underneath have all been removed. All the openings/vents on the outside have been checked and repaired (when needed). Parent's were notified of the probem on an ongoing basis and provided updates when available. The problem has since been corrected and children are able to be back inside their regular preschool areas. Facility took many measures to resolve the issue and to date, the problem has been resolved.

Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 12, Chapter 1:

Notice of site visit provided and must remain posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Andrea Medlin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
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-20231009150206
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TRINITY LUTHERAN PRESCHOOL
FACILITY NUMBER: 414002946
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2023
Section Cited
CCR
101223(a)(2)
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PERSONAL RIGHTS: The licensee shall ensure that each child is accorded the following personal rights: To be accorded safe, healthful and comfortable accommodations. This requirement is not met based on it being reported facility was having problems with fleas inside resulting
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Facility has already corrected the problem with exterminators and the preschool has been fumigated. LPA already obtained copies of the exterminator's reports and other misc documents.
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in some children getting flea bites. This poses a potential health and safety risk.
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Deficiency is corrected and cleared today.
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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: Daniel J Oquendo
LICENSING EVALUATOR NAME: Andrea Medlin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2