Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002299
Report Date: 06/27/2018
Date Signed: 06/27/2018 02:28:17 PM

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: 31DATE:
06/27/2018
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Joseph WisemanTIME COMPLETED:
09:30 AM
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LPA Ng made a case management inspection to the facility at issue, present was the Director, Joseph Wiseman and 5 staff and 31 children. The facility was advised for the reason of the visit. At issue was a report from the facility that a child was injured using a board. Upon further inspection of the board, this was a commercially available balancing board. Available information through interviewing the Director shows that the small circular balancing board was being utilized by a child when he lost balance and hit his head towards the wall. The child has since returned to school without any known issues after returning from medical examination. LPA inspected the playground area at issue and recommended that some type of cushioning can be applied to the wall where the child got injured, this is an area where some gross motor activities are held. The Director agreed to order padding and apply it to the walls to prevent children from getting injured. There is no observed deficiencies, the staff had supervised the child and immediate first aid attention was provided.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2018
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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