Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002299
Report Date: 06/21/2018
Date Signed: 06/21/2018 12:39:03 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: 21DATE:
06/21/2018
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Joseph WisemanTIME COMPLETED:
12:30 PM
NARRATIVE
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LPA made an investigation visit to the facility at issue, the facility made a report to Licensing that a child was hurt. The facility has complied with regulations to report the incident to Licensing. Present was Joseph Wiseman, with 4 staff and 21 children. The reason for the visit was to investigate an incident where a child was discovered to have a rope burn on the neck area. LPA conducted an inspection of the playground and its play materials and interviewed staff. In the process of the investigation it is found that there was a lack of supervision for the children at play, and that the choice of play material may not be a safe option. Information provided that children were engaged in a game of chase that involved using ropes to catch the person being chased. Staff states that they did not see the incident and the child made no indication that he was hurt. The child at issue did receive a rope burn which the parent had noticed in the evening and this was communicated to the facility the next day. The facility has since provided training and met with the staff in regards to safety and supervision of children.

Licensee has been informed that the LIC9213 and all type "A" citations need to be posted for 30 days, this report shall remain in the facility and be kept for public review upon request. If type "A" citations were issued, this report will be reviewed with parents. As proof of review form LIC9224 will then be given to all current parents for signature and be kept in each child's file. For the next 12 months all parents newly enrolled children shall also be provided information contained in this report and a copy of the LIC9224 will also be signed and placed in each child's file. As an applicant or licensee it is your right to file an appeal if you disagree with an action taken by the licensing agency or its representative. File your appeal with the Regional Manager, within 15 business days from the date you receive this report or penalty assessment noticed.

Erin Farris, Head Teacher signed for Joseph Wiseman (scheduled meeting and not available for signature.)
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2018
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2018
Section Cited
CCR
101229(a)(1)
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101229(a)(1) Care and Supervision:

No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).
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Director has provided a Care and Supervision memo to all staff and conducted an expectations meeting with staff. Director has conducted a training on Safety and Supervision with staff. Subject matter and staff signatures will be sent to LPA by 06/26/18.
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This requirement was not met as evidenced by: Base upon interviews, licensee failed to protect C1 from physical harm, under the direction of S1,2,3. This poses an immediate safety risk to 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: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2018
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2018
Section Cited
CCR
101238(a)
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101238(a) Buildings and Grounds. The child care center shall be clean, safe, sanitary and in good repair at all times.

This requirement was not met as evidence based upon inspection of the play materials and Staff interview,

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Director states that he will have a review of all play materials with staff and review if items used for children are safe and age appropriate. The later in regards to the loose cords were immediately removed or made inaccessible to the children and not usable without adult supervision
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Licensee failed to provide safe play materials or age appropriate materials resulting injury to C1 . Also inspection of loose cords that may trip or choke children were observed in the outside play space.
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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: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2018
LIC809 (FAS) - (06/04)
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