Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002299
Report Date: 08/03/2016
Date Signed: 08/03/2016 11:25:38 AM

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:C5 CHILDREN'S SCHOOL-SFPUC (PS)FACILITY NUMBER:
384002299
ADMINISTRATOR:WISEMAN, JOSEPHFACILITY TYPE:
850
ADDRESS:525 GOLDEN GATE AVENUETELEPHONE:
(415) 626-4880
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:45CENSUS: 33DATE:
08/03/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Roxanne ResumaTIME COMPLETED:
11:30 AM
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LPA Ng made a case management visit to the facility at issue, present was Roxanne Resuma, Site Director with 33 children and 6 teachers. The reason for the visit was explained to the Site Director. The facility had self reported an incident that happened at the school where a child had tried to climb a shelf and the shelf fell on him. Staff were interviewed and after information was gathered this incident can be supported by the information that it was an accident. Since the incident the facility has met with staff, discarded the article that may contribute to future incidents and had also did a self assessment of all furniture in the facility was conducted and management had decided to secure all furniture that had any kind of height to it. LPA is satisfied that the incident was an isolated accident, the ratio of staff to children was and remains at approximately 7:1. There was staff present at the incident and the facility has taken corrective actions to prevent future incidents from occurring. This matter will be considered to be closed. A tour of the facility was conducted to look for other potential dangers and advisories were presented to the Site Director.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2016
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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