Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002637
Report Date: 01/11/2018
Date Signed 01/11/2018 12:17:48 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:SFUSD-JOSE ORTEGA ES (EED) PSFACILITY NUMBER:
384002637
ADMINISTRATOR:JOLYNN T. WASHINGTONFACILITY TYPE:
850
ADDRESS:400 SARGENT ST, RM 001 & B-8TELEPHONE:
(415) 750-8505
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:48CENSUS: 24DATE:
01/11/2018
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Tiffany O'neallTIME COMPLETED:
12:50 PM
NARRATIVE
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PMLicensing Program Analyst (LPA) Mok conducted an unannounced case management inspection for an incident that happened on December 12, 2017. LPA met with the head teacher, Tiffany O'neal, in B-8 classroom, The purpose of the inspection was explained to her. There were 24 children with 5 staff present. Tiffany called to the desk duty and reported the incident on 12/14/17. The incident happened on 12/2/17. One of the students in Special Day Class tripped and fell on the Easel that was hanged on the fence at the playground. Per Tiffany, she was sitting on the bench near by the child. The height of the benches were low. The child walked in the beginning, and then started running on the bench when she asked him to come to her. However, the child was tripped over his feet and fell on the Easel that was hanged between the benches. Tiffany saw the incident, but she couldn't stop it since it happened too fast. The child had a gash on his forehead. The doctor put the glue on his wound. The child came back to school next day. LPA inspected the playground for health and safety hazard,. LPA didn't observed any tripping hazard at the playground. Per Tiffany, facility already removed the easel from the fence after the incident. They try to purchase another type of easel that may minimized for the children.

*no deficiency was issued during the inspection*.


This report and notice of site visit were discussed with the licensee and must be made available to the public upon request. For quarterly update on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy MokTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2018
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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