Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410519011
Report Date: 02/08/2018
Date Signed 02/08/2018 02:50:26 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:CSSF REC DEPT-PONDEROSA AFTER SCHOOL REC PROGRAMFACILITY NUMBER:
410519011
ADMINISTRATOR:CRISTINA RODRIGUEZFACILITY TYPE:
840
ADDRESS:295 PONDEROSA ROADTELEPHONE:
(650) 873-1096
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:120CENSUS: 16DATE:
02/08/2018
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Kimberly Morrison, Laura Armanino, Kelli CullinanTIME COMPLETED:
02:55 PM
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LPA Andrea Medlin met with staff for this case management visit. Purpose of the visit is due to a self reported unusual incident. On January 22, 2018, a child (C1) was writing inappropriate comments in his journal that had threatening remarks towards another child (C2). C1 had then attempted to pass the note to C2, however staff intercepted it. C1 then ran out of the classroom and off campus; a staff person chased after him and child was in sight the entire time. Child was then brought back to the classroom and parents were called. South San Francisco Police was notified and subsequently visited both homes of the children regarding the incident. Staff had a meeting with both parents in their office on 1/25/18. The plan in the future is to have children do conflict resolution where they use their words and staff monitor the children. Children are also offered time in the "quiet corner" if needed to be away from the group. Facility staff also send out "discipline guidelines" to all parents as a reminder of appropriate behavior.

This report was reviewed with Recreation and Community Services Supervisor and a copy of this report must be made available for public review upon request.

Notice of site visit posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2018
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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