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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004114
Report Date: 10/14/2022
Date Signed: 10/14/2022 04:12:30 PM

Document Has Been Signed on 10/14/2022 04:12 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: 61DATE:
10/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Jenny HobsonTIME COMPLETED:
04:25 PM
NARRATIVE
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On 10/14/2022 at 1:50PM. Licensing Program Analyst, (LPA) Luis J. Gomez met with Director, Jenny Hobson. Purpose of inspection was explained and was for an unannounced, case management inspection in response to two facility- reported incidents. Present was the director and 8 staff supervising 61 children. LPA inspected facility, indoors and outdoors, for health and safety hazards.

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

-On 7/8/2022, preschool child in the Monarch #1 classroom was left outside without staff supervision for several minutes during transition.
-On 9/20/2022, preschool child in the kindergarten preparation class had eloped from classroom, and was left unsupervised for several minutes.

Director stated after incidents occurred, authorized representatives were immediately notified.

As a result of the incident, a violation of Title 22 Division 12 of Ca. Code of Regulations was observed, and a deficiency was cited on the attached 809D.



Type “A” violation was issued today. Director was advised to provide a copy of the Evaluation Report and all Type “A” Deficiencies cited, to parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 (Deficiency and Acknowledgment of Receipt of Licensing Reports) shall be maintained in all children's files.

A civil penalty of $250.00 was assessed during inspection.

An exit interview was discussed with Director. A copy of this report, plan of correction and appeal rights were provided. Signature of this form acknowledges receipt of these documents.

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, 8:00AM- 5:00PM, 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: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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 10/14/2022 04:12 PM - It Cannot Be Edited


Created By: Luis Gomez On 10/14/2022 at 03:29 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: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2022
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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Authorized representives will sign the LIC9224, 'Notice of A-type deficiency' by the due date: 10/20/2022.

Proof of correction will be submitted to the department via email.
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Based on interviews and record review, LPA confirmed day-care child(ren) were left without staff supervision for several minutes. This poses an immediate health and safety risk to children in care.
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Non- Compliance Conference will be scheduled at the San Bruno Childcare Regional Office at a later date.

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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: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022


LIC809 (FAS) - (06/04)
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