Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410517312
Report Date: 11/29/2017
Date Signed 11/29/2017 05:14:33 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
11/22/2017 and conducted by Evaluator Katie L Kistler
COMPLAINT CONTROL NUMBER: 05-CC-20171122084633
FACILITY NAME:NEIGHBORHOOD KIDS' CORNERFACILITY NUMBER:
410517312
ADMINISTRATOR:MCAFEE, SUSANFACILITY TYPE:
840
ADDRESS:3790 RED OAK WAYTELEPHONE:
(650) 365-6117
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:90CENSUS: 32DATE:
11/29/2017
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Susan McafeeTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Other - Facility failed to adhere to the terms of the Admission Agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kistler met with Site Supervisor, Susan Mcafee for an unannounced complaint inspection. The purpose of the inspection was to begin the investigation of the above allegations.

On this day, LPA interviewed staff and children and reviewed the facility admission agreement. Based on information obtained, the program dismissed a child from the program without following all the steps outlined in the discipline policy. Based on LPA's interviews which were conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12 & Chapter1), are being cited on the attached LIC 9099D. A copy of this report and rights appeal were provided to the facility. Notice of Site visit was observed to be posted and shall remain posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Katie L KistlerTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2017
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-20171122084633
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: NEIGHBORHOOD KIDS' CORNER
FACILITY NUMBER: 410517312
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2017
Section Cited
CCR
101219(a)
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101219 Admission Agreements
(a) The licensee and the child's authorized representative shall jointly complete a current individual written admission agreement for the child.
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By 12/15/17; the site director has agreed to update the admission agreement and discipline policy. Copy of the updated agreement will be provided to the department.
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The facility dismissed a child from the program without following all the steps outlined in the discipline section of the admission agreement.
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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: Katie L KistlerTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2017
LIC9099 (FAS) - (06/04)
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