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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004114
Report Date: 04/05/2022
Date Signed: 04/05/2022 01:20:14 PM

Document Has Been Signed on 04/05/2022 01:20 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PAPILLON PRESCHOOL MANAGED BY BRIGHT HORIZONSFACILITY NUMBER:
414004114
ADMINISTRATOR:JENNY HOBSONFACILITY TYPE:
850
ADDRESS:1311 SO. EL CAMINO REALTELEPHONE:
(650) 340-7241
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 84TOTAL ENROLLED CHILDREN: 84CENSUS: 83DATE:
04/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jenny HobsonTIME COMPLETED:
01:40 PM
NARRATIVE
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On 4/5/2022 at 10:10A.M. Licensing Program Analyst, (LPA) Luis J. Gomez met with Director, Jenny Hobson. The purpose of today's inspection was explained and is in response to an incident that had occurred on March 1, 2022. Incident was self- reported to the department by the facility management, and involved a preschool child who had been left alone inside of the butterfly classroom. Present was the director and 10 staff supervising 83 children. All children present had been properly signed-in. LPA inspected facility, indoors and outdoors, with director for health and safety hazards.

During the inspection, LPA performed site observations, interviewed staff, director and all involved parties.

During interviews, it was reported that on 3/1/2022 at 3:45P.M., staff member, S3, had observed child, C1, alone inside one of the preschool classrooms (Butterfly #1). Per staff, child, C1, was left unattended for several minutes. Director stated after the incident occurred, she immediately notified the child’s authorized representatives.

On 3/3/2022, Facility conducted policy training with all classroom personnel to review their policy regarding constant, visual supervision of day-care children. Policy training also reviewed proper child tracking strategies for staff. Training agenda and sign-in and proof of participation forms were submitted to LPA during today's inspection.

Director stated she will continued to emphasize to staff the importance of performing child classroom child counts, especially before and after transitions to and from facility play yard and bathroom use.

As a result of the occurrence of this incident, a violation of the Title 22 Division 12 of Ca. Code of Regulations was observed, and deficiency was cited on the attached 809D. An exit interview was discussed with Director. A copy of this report with the appeal rights was provided, and signature of this form acknowledges receipt of these documents.

Deficiency was cleared by LPA during inspection.

Notice of Site Visit for was provided during inspection.

This report must be available in the facility for public review. Director was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 04/05/2022 01:20 PM - It Cannot Be Edited


Created By: Luis Gomez On 04/05/2022 at 12:34 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: PAPILLON PRESCHOOL MANAGED BY BRIGHT HORIZONS
FACILITY NUMBER: 414004114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2022
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Responsible for providing Care and Supervision: 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 is not met as evidenced by:
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On 3/3/2022, Site director held staff training to discuss policy regarding constant visual supervision of day-care children and tracking strategies for classroom staff.

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Based on interviews and file review, LPA confirmed child, C1, was left alone inside classroom for several minutes. This poses a potential health and safety risk to children in care.
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Deficiency was cleared by LPA during today's inspection.

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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:Cindy Interiano
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022


LIC809 (FAS) - (06/04)
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