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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004884
Report Date: 06/15/2023
Date Signed: 06/15/2023 12:49:53 PM

Document Has Been Signed on 06/15/2023 12:49 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:EMPIRE INFANTFACILITY NUMBER:
414004884
ADMINISTRATOR:SARAH JENFACILITY TYPE:
830
ADDRESS:3080 LA SELVA STREETTELEPHONE:
(650) 678-3638
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 20TOTAL ENROLLED CHILDREN: 16CENSUS: 15DATE:
06/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Bonnie Li and Sarah JenTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marie Rodriguez conducted an unannounced case management inspection in-conjunction with closing two complaints under the preschool license #414004883. LPA met with facility representative and Lead Teacher (in the preschool program) Bonnie Li and explained purpose of inspection.

Upon arrival at 8:45am, LPA observed six infants and Lead Teacher in the infant classroom. Three more infants arrived before a second teacher (T1) arrived around 9:00am. By 9:15am, infant lead teacher Sarah Jen, teacher's assistant (T2) and Licensee Linda Tong arrived along with two more children. Lead Teacher Bonnie Li moved to a classroom in the preschool program during this period.

Deficiency cited today under California Code of Regulations, Title 22, Division 12, which follows on LIC 809D.

LPA Marie Rodriguez informed facility representative Bonnie Li that this report dated June 15, 2023 documents one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health and safety of children in care.

Also, LPA Marie Rodriguez informed facility representative to provide a copy of this licensing report dated June 15, 2023 that documents any Type A citation 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.

Exit interview conducted and report was reviewed with facility representative Bonnie Li. A copy of the Appeals Rights was provided. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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 06/15/2023 12:49 PM - It Cannot Be Edited


Created By: Marie Rodriguez On 06/15/2023 at 10:43 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: EMPIRE INFANT
FACILITY NUMBER: 414004884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2023
Section Cited

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Staff-Infant Ratio
(b) There shall be a ratio of one teacher for every four infants in attendance.

This requirement has not been met as evidenced by:
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LPA Marie Rodriguez observed upon arrival to the facility that there was only one teacher with six infants in care which poses an immediate health and safety risk to children in care.
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An immediate civil penalty of $500 will be 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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
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