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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005081
Report Date: 11/26/2024
Date Signed: 11/26/2024 10:22:06 AM

Document Has Been Signed on 11/26/2024 10:22 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:BUILDING KIDZ SCHOOLFACILITY NUMBER:
414005081
ADMINISTRATOR/
DIRECTOR:		SMITH, JESSICAFACILITY TYPE:
860
ADDRESS:1633 LAUREL STREETTELEPHONE:
(650) 718-6800
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 23DATE:
11/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Director, Jessica SmithTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
NARRATIVE
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On 11/26/2024, at approximately 8:30AM, Licensing Program Analysts (LPAs) Jonathan Tse and Jaclyn Naves conducted an unannounced case management visit regarding a self-reported incident. LPAs met Director, Jessica Smith and explained the purpose of the visit. Present during the visit was Director, nine staff 17 preschool age children, and six infants.

The facility submitted an incident report on 11/12/2024 for an incident that occurred on 11/8/2024. A child was left unsupervised in the facility's outdoor play area for approximately four minutes. The facility reported the incident to the child's parent and notified the Regional Office within seven days.

During the visit, LPAs conducted site observations, record review, and interviewed the Director. Per Director, individual meetings and a general staff meeting were conducted. Supervision policies and procedures were discussed. Name-to-face and frequent counts were discussed. LPAs observed the facility to be operating within staffing and ratio requirements on this day. Children were within visual supervision of a teacher at all times during the visit. Based on interviews and record reviews, the facility did leave a child unsupervised in the outdoor play area. LPAs acquired signed meeting memos from the staff members involved during the visit. The facility has taken steps to address the violation and ensure that all staff are aware of supervision and transition procedures. LPAs informed Director that a Type B deficiency would be cited and cleared during today's visit.

During the visit, LPAs observed that one staff member, S1, was not associated to the facility. Per Director, S1 had prior fingerprint clearance. LPAs checked S1's fingerprint clearance and found that they had an active fingerprint clearance. Director filled out a Criminal Background Clearance Transfer Request form (LIC9182) and provided it to LPAs during the visit. S1 was associated to the facility by LPAs. LPAs informed Director that a Type A deficiency would be cited and a civil penalty of $100 assessed during today's visit. Director stated that they understood.
Continued on Page Two
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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 03/06/2025 11:50 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/06/2025 11:35 AM


Created By: Cindy Interiano On 11/26/2024 at 09:15 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BUILDING KIDZ SCHOOL
FACILITY NUMBER: 414005081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/27/2024
Section Cited
CCR
101170(e)(2)

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***THIS IS AN AMENDMENT OF ORIGINAL REPORT DATED 11/26/24***
***Deficiency has been modified from a TYPE A violation to a TYPE B violation.***
Criminal Record Clearance 101170(e)(2)
(2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or...

This requirement was not met as evidenced by:
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LPAs found that S1 did have an active fingerprint clearance during the visit. Director filled out LIC9182 and provided it to LPAs during the visit. S1 was then associated to the facility. This deficiency shall be cited and cleared the same day of the visit.
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Based on observations, record review, and interviews, LPAs found that a staff member, S1, did not have association to the facility during the visit. This posed a potential risk to the health, safety or personal rights 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:Carol Marcroft
LICENSING EVALUATOR NAME:Cindy Interiano
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 3 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BUILDING KIDZ SCHOOL
FACILITY NUMBER: 414005081
VISIT DATE: 11/26/2024
NARRATIVE
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Page Two

***THIS IS AN AMENDMENT OF ORIGINAL REPORT DATED 11/26/2024.***

See LIC809-D for deficiencies cited and cleared during today's visit. Appeal rights were provided and explained to the Director. A notice of site visit was provided and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Jessica Smith.
SUPERVISORS NAME: Carol Marcroft
LICENSING EVALUATOR NAME: Cindy Interiano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/26/2024 10:22 AM - It Cannot Be Edited


Created By: Jonathan Tse On 11/26/2024 at 09:47 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: BUILDING KIDZ SCHOOL
FACILITY NUMBER: 414005081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2024
Section Cited
HSC
101229(a)(1)

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(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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The facility conducted staff meetings to ensure that all staff understand supervision and transition procedures. This deficiency shall be cited and cleared the same day of the visit, 11/26/2024.
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Based on record review and interviews, LPAs confirmed that a child was left without supervision in the outdoor play area for approximately four minutes. This posed a potential risk to the health, safety, or personal rights 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:Ali Zebila
LICENSING EVALUATOR NAME:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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