Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414002877
Report Date: 06/28/2017
Date Signed: 06/28/2017 12:37:47 PM


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
04/18/2017 and conducted by Evaluator Cindy Mok
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20170418101653
FACILITY NAME:PFS-BAYSHORE MIDWAY CDC (PS)FACILITY NUMBER:
414002877
ADMINISTRATOR:CREEDON, JEANNIEFACILITY TYPE:
850
ADDRESS:45 MIDWAY DRIVETELEPHONE:
(415) 330-1717
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:95CENSUS: DATE:
06/28/2017
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Marisol OstorgaTIME COMPLETED:
10:35 AM
ALLEGATION(S):
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Personal Rights: Staff handled child inappropriately
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mok conducted an unannounced inspection finalize this complaint. LPA met with the Site Director, Marisol Ostorga. The purpose of the inspection was explained to her . There were 78 children with 24 staff that included 5 sub teachers present. . During the investigation, LPA Mok conducted interviews & obtained copies of the relevant documents regarding the allegation.

Based on the interview conducted and relevant documents gathered, the preponderance of evidence standard has been met. Teacher unintentionally scratched a child's neck when she tried to stop the child throwing the plate and spoons in the air, and running around in the classroom. Therefore the above allegation was found to be SUBSTANTIATED.

*See next page of a deficiency that was cited during visit. *

An exit interview was conducted with the site director & appeal rights were explained. A printed copy of the report and appeal rights were provided to them at the conclusion of the visit.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy MokTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 05-CC-20170418101653

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: PFS-BAYSHORE MIDWAY CDC (PS)
FACILITY NUMBER: 414002877
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2017
Section Cited
101223(a)(1)
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Personal Rights:

**Teacher unintentionally scratched the child's neck when she tried to stop the child throwing plates and spoons in the air and running around in the classroom. **
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Each child shall be accorded dignity in his/her personal relationships with staff, and other persons. Faciltiy shall provide training to all staff and submit the copies of the training material and signature of attendees to CCL by the due date (7/12/17).
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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: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy MokTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2017
LIC9099 (FAS) - (06/04)
Page: 2 of 2