Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002299
Report Date: 10/01/2019
Date Signed: 10/01/2019 11:01:53 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:SHERAN LOFACILITY TYPE:
850
ADDRESS:525 GOLDEN GATE AVENUETELEPHONE:
(415) 626-4880
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:45CENSUS: 28DATE:
10/01/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sheran LoTIME COMPLETED:
11:00 AM
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On 10/01/19 at 09:00 A.M., Licensing Program Analyst (LPA) Van conducted an unannounced case management and met with the director Sheran Lo. The purpose of this inspection was explained and was granted entry to inspect the facility by the facility staff. Facility self reported an unusual incident that occurred on September 6, 2019. Present there are 28 children and 6 teachers.

The unusual incident was reported by Center Director, Sheran Lo where a child was sustained an injury to his chin. In today’s inspection, LPA inspected the outdoor space, play equipment, and interviewed teachers that were present and observed the incident. Teachers stated this incident occurred during the outdoor exploration, where children would create their own slide using padded board. It was C1's turn to go down the slide, instead of slide down he decided to jump on the padded board. The padded board collapsed and C1 bumped his chin on the wooden bench. Based on the evidence obtained, supervision was not the issue, director stated on mentioned date, there were 2 teachers supervised 18 children in the play yard. The facility was in ratio at the time of the incident, and there were no deficiencies discovered or observed.

Moving forward, Center Director planned to not use the padded board for children to make sliding board to minimize the risk of injuries.

No deficiencies were cited today. Notice of site visit posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2019
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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