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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004416
Report Date: 04/07/2023
Date Signed: 04/07/2023 11:52:36 AM

Document Has Been Signed on 04/07/2023 11:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:WAGENHALS,KATHLEENFACILITY NUMBER:
384004416
ADMINISTRATOR:WAGENHALS, KATHLEENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 902-3312
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94131
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
04/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Kathleen WagenhalsTIME COMPLETED:
12:00 PM
NARRATIVE
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 On April 7, 2023., Licensing Program Analysts (LPAs) Van and Leong conducted an announced case management in conjunction with delivering the findings to the complaint. The purpose of this case management was explained to the Licensee. The Department received information that an incident involving the Licensee and two children under Licensee's care occurred on March 16, 2023. The Licensee contacted Law enforcement at her facility, where an acquaintance of the Licensee attempted to break into the home, and the ordeal was in the presence of the children in care. After further review of the incident timeline, it was determined that there was a failure to report the unusual incident to Community Care Licensing as required.
The following Title 22, Division 12, Chapter 1, Article 6 deficiency is being cited on the following page for failure to report the incident:
Licensee Kathleen Wagenhals read and signed the report. Today's report, site visit notice, deficiency, and appeal rights were provided to the Licensee. LPAs informed the Licensee that a site visit notification must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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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Document Has Been Signed on 04/07/2023 11:52 AM - It Cannot Be Edited


Created By: Brendon Van On 04/07/2023 at 11:22 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: WAGENHALS,KATHLEEN
FACILITY NUMBER: 384004416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
102416.2

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102416.2 Reporting Requirements
(b)The Licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. (C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child."
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Licensee will report the unusual incident report to Community Care Licensing using the LIC 624B Unusual Incident/Injury Report form and include details of any follow-up completed from when the Licensee was made aware of the incident. Licensee will review section 102416.2 of the Regulation regarding Reporting requirements and submit a plan to prevent this deficiency from reoccurrence.
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This requirement was not met, as evidenced by the record review. The Licensee failed to report to Community Care Licensing an unusual incident involving an acquaintance of the Licensee, broke into the home, and police were called while the children were in care. Failure to report unusual incidences as required to the Department could present potential health and safety risks to the children.
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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:Garfield Leung
LICENSING EVALUATOR NAME:Brendon Van
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
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