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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004812
Report Date: 03/28/2024
Date Signed: 03/28/2024 09:54:36 AM

Document Has Been Signed on 03/28/2024 09:54 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:PRIMARY SCHOOL, THEFACILITY NUMBER:
414004812
ADMINISTRATOR:EASTER, KYNDALFACILITY TYPE:
850
ADDRESS:2086 CLARKE AVENUETELEPHONE:
(650) 396-2779
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 98TOTAL ENROLLED CHILDREN: 94CENSUS: 0DATE:
03/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:ECE Dean, Tajmah Martin and Dean of Operations, Reyna NietoTIME COMPLETED:
10:15 AM
NARRATIVE
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On March 28th, 2024 at approximately 8:30am, Licensing Program Analyst (LPA) Tapia-Mandujano arrived at the facility to conduct a Case Management-Incident inspection. LPA met with ECE Dean, Tajmah Martin and Dean of Operations, Reyna Nieto. The purpose of today's inspection was explained. Inspection is in response to an Unusual Incident Report that was self reported and received by the department on February 29th, 2024.

Facility operates in Classrooms #3,4,5,6,7, and 12. Facility is closed for a Professional Development Day, there are no children present. LPA inspected the classroom and outdoor area where the incident happen.

The facility self reported an incident that occurred on February 28th, 2024. The incident involved lack of supervision that resulted in a child being left unsupervised inside of the classroom. Per interview and record review of incident received, a child was left alone inside a classroom for approximately 3 minutes. Per ECE DIrector the staff failed to the do the second headcount resulting in a child being left alone in the classroom. Per ECE Director, another classroom staff found the child and brought child outside with the rest of the group.

During today's inspection, LPA spoke with ECE Dean, Tajmah, about the immediate actions that were taken. Per conversation with ECE Dean, the action plan has been modified to take disciplinary action. All staff are being constantly reminded of the policies of supervision and hands on training is implemented. Per ECE Director, they have added doing real time feedback to staff as transitions are happening. Facility also implemented a name to face mechanism. Parent of unsupervised child was notified.

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PRIMARY SCHOOL, THE
FACILITY NUMBER: 414004812
VISIT DATE: 03/28/2024
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Due to the repeat violation, a Type A deficiency has been issued and civil penalties were assessed. Please see LIC 809D for more details.

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

LPA informed ECE Director, Tajmah Martin that this report dated 03/28/24 documents a Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA informed the ECE Director, Tajmah Martin to provide a copy of this licensing report dated 03/28/24 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.


This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit. An exit interview was conducted with ECE Dean, Tajmah Martin and Dean of Operations, Reyna Nieto.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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Document Has Been Signed on 03/28/2024 09:54 AM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 03/28/2024 at 09:21 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: PRIMARY SCHOOL, THE
FACILITY NUMBER: 414004812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2024
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... Supervision shall include visual observation."

This requirement was not met as evidenced by:
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Facility has submitted an Updated Action Plan.

Office Meeting will be scheduled.
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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 there was a child left alone inside the classroom during outdoor play, which poses an immediate health, safety or personal rights risk to persons in care.
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Civil Penalties were assessed.

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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: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024


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