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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004884
Report Date: 04/27/2023
Date Signed: 04/27/2023 08:14:01 PM

Document Has Been Signed on 04/27/2023 08:14 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: 18CENSUS: 14DATE:
04/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sarah Jen and Bonnie LiTIME COMPLETED:
08:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marie Rodriguez conducted a case management inspection in-conjunction with an annual continuation inspection. LPA met with Director Sarah Jen and explained purpose of inspection.

Upon arrival into the building where the center was located at, LPA saw the LIC 9213 Notice of Site Visitissued on April 14, 2023 posted on the bulletin board of the entry way into the building but the corresponding LIC 809 Facility Evaluation Reportand LIC 809-D deficiency page for the type A citation issued on the same day were not posted on the bulletin board.

LPA asked Director where the report and deficiency page were located at. Upon arrival inside the center, LPA saw LIC 809 report and LIC 809-D deficiency page were on a table with a stack of printed LIC 9224 Acknowledgement of Receipt of Licensing Reportssitting underneath them on a clipboard. Per LPA's review of the LIC 9224 forms, not all parents have signed them as required after a type A citation was issued.

At 4:30pm, LPA went inside center to find facility representatives to discuss annual continuation inspection and previous plan of corrections (POCs), when LPA saw two teachers and one teacher's assistant with 14 infants in care. Third teacher was between the infant and preschool classrooms and returned to the preschool classroom 1. Infant program did not have the correct staff to child ratio of 1:4.

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

An immediate civil penalty of $100 was assessed for failure to comply. An immediate civil penalty of $500 was assessed for absence of supervision.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 04/27/2023 08:14 PM - It Cannot Be Edited


Created By: Marie Rodriguez On 04/27/2023 at 02:26 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: EMPIRE INFANT
FACILITY NUMBER: 414004884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited
HSC
1596.8595(a)(1)

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Each licensed child day care facility shall post a copy of any licensing report pertaining to the facility that documents either a facility visit or a complaint investigation that results in a citation for a violation that, if not corrected, will create a direct and immediate risk to the health, safety, or personal rights of children in care. The licensing report provided by the department shall be posted immediately upon receipt, adjacent to the postings required pursuant to Section 1596.817 and on, or immediately adjacent to, the interior side of the main door to the facility and shall remain posted for 30 consecutive days.
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Facility representative will ensure that LIC 809 and LIC 809D page is posted on the bulletin board and will provide LPA with a picture after it has been posted via email by the POC due date.
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This requirement has not been met as evidenced by:

LIC 809 Facility Evaluation Report and LIC 809-D were not posted on the bulletin board along side the Notice of Site Visit issued on 4/13/23 which poses an immediate health and safety risk to children in care.
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An immediate civil penalty of $100 has been assessed.
Type A
04/28/2023
Section Cited
1596.8595(c)(1)

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A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b
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Facility representative will ensure to provide parents with a copy of LIC 809 and LIC 809D to review and have them sign LIC 9224. Facility representative will provide LPA with a list of parents signing off that they received a copy of report via email by POC due date.
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This requirement has not been met as evidenced by:

LIC 809 Facility Evaluation Report and LIC 809-D were located inside the entrance of the center on a clipboard along with LIC 9224 Acknowledgement of Receipt of Licensing Reports. Per review of the clipboards, not all parents received and signed the LIC 9224 as required for a type A violation which is an immediate risk to the health and safety of children in care.
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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: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: EMPIRE INFANT
FACILITY NUMBER: 414004884
VISIT DATE: 04/27/2023
NARRATIVE
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LPA informed facility representative Bonnie Li that this report dated April 27, 2023 documents three Type A citations 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 facility representative to provide a copy of this licensing report dated April 27, 2023 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.

Exit interview conducted and report was reviewed with facility representative Bonnie Li. Appeals Rights were given.

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: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/27/2023 08:14 PM - It Cannot Be Edited


Created By: Marie Rodriguez On 04/27/2023 at 05:45 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: EMPIRE INFANT
FACILITY NUMBER: 414004884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited
CCR
101416.5(b)

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Staff-Infant Ratio

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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Facility representative will provide LPA with a facility sketch showing the appropriate qualified staff for each classroom.

POC was corrected during inspection.
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Per LPA's observation at 4:30pm, there were two teachers and one teacher's assistant with 14 infants in the classroom. This 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: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
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