Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 384002299
Report Date: 09/12/2018
Date Signed: 09/12/2018 10:34:31 AM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2018 and conducted by Evaluator Tony Ng
COMPLAINT CONTROL NUMBER: 05-CC-20180622091424
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:
09/12/2018
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Sheran LoTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff failed to safeguard familys and children's personal information
Facility did not report incident

INVESTIGATION FINDINGS:
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LPA made a closing complaint visit to the facility at issue, present was the director, Sheran Lo with 4 staff and 21 children. Based on LPAs observations and interviews with staff and parents which were conducted and record review(s), which provided information that a person had scaled the 10 feet high fence to steal a back pack that was left by staff in the outside area containing family information and that the incident was not reported on a timely matter. Tthe preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12 & Chapter 1, 101221(c)(1) and 101212(d) number), are being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2018
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2018 and conducted by Evaluator Tony Ng
COMPLAINT CONTROL NUMBER: 05-CC-20180622091424

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: DATE:
09/12/2018
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
Staff placed daycare child in soiled under garment
INVESTIGATION FINDINGS:
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LPA made a closing complaint visit to the facility at issue, present was the director, Sheran Lo with 4 staff and 21 children. Information available shows that the facility did clean the child as evidenced by the use of clean loaner clothing, but when the final soiling of the child took place is unclear. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2018
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 05-CC-20180622091424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/12/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2018
Section Cited
CCR
101221(c)(1)
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(c) All information and records obtained from or regarding children shall be confidential.
(1) The licensee shall be responsible for safeguarding the confidentiality of record contents.


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Director states that they have trained staff for proper end of day procedures. LPA explained the requirements of the law to the Director. Deficiency is cleared and corrected.
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This requirement is not met as evidenced by:

The facility having left a back pack in the outside play space and then a person scaled the fence and stole the back pack. with Emergency contact information.
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Type B
09/14/2018
Section Cited
CCR
101212(d)
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(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.
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Director had sent in the incident report upon investigation of the incident. LPA explained to the Director the requirements under title 22. Deficiency is cleared and corrected.
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In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. This requirement is not met as evidenced by: The stolen back pack incident was not reported
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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: 09/12/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2018
LIC9099 (FAS) - (06/04)
Page: 2 of 4