Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410517854
Report Date: 09/30/2015 12:00:00 AM
Date Signed 09/30/2015 03:53:39 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:A CHILD'S WAYFACILITY NUMBER:
410517854
ADMINISTRATOR:LAWSON, NANCI ROTHFACILITY TYPE:
840
ADDRESS:801 HOWARD AVE.TELEPHONE:
(650) 342-3460
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:70CENSUS: 57DATE:
09/30/2015
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ramona HernandezTIME COMPLETED:
04:00 PM
NARRATIVE
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LPAs Yee and Kistler conducted a case management visit today. This is a self reported incident occurred on September 3rd, involving a child who was climbing on the monkey bar and fell. Today, LPAs interviewed four teachers. On the day of the accident there were 4 teachers, 1 flooder and 40 children outside. T1, T2, T3, T4 did not witness the accident at the time of the incident. A child was on the monkey bar, T5 was supervising the child, at the same time another child needed her attention and she turned around to attend another child. The child who was on the monkey bar slipped and fell. The child was injured.

See next page for type B citation.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8843
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2015
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: A CHILD'S WAY
FACILITY NUMBER: 410517854
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2015
Section Cited
101229(a)(1)
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Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).

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Faility needs to come up with the plan of correction by due date.
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T5 went to attend another child and the child who was on the monkey bar slipped and fell. The child was injuried
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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) 266-8843
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2015
LIC809 (FAS) - (06/04)
Page: 2 of 2