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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108889
Report Date: 10/05/2020
Date Signed: 10/06/2020 09:49:24 AM

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:C.A.M.- OLD GALLINAS CHILDREN'S CENTER (SA)FACILITY NUMBER:
210108889
ADMINISTRATOR:MARIN-LIMA, IRISFACILITY TYPE:
840
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 479-2771
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:103CENSUS: 13DATE:
10/05/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
12:15 AM
MET WITH:Paula CifuentesTIME COMPLETED:
12:45 AM
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Licensing Program Analyst (LPA) Farhan Bashir-Tariq met with C.A.M quality Support Manager, Paula Cifuentes to conduct an announced case management inspection today. This inspection was conducted via FaceTime due to COVID-19. Purpose of inspection was explained and was to review a portable room #28 for health and safety hazards. This room will be used temporarily until June 2021 to accommodate school age program due to COVID-19. This temporary addition will not affect facility's current capacity. Facility is a combination center with preschool program running at the same site. There were 13 children present today.

LPA toured the room with Paula for health and safety hazards. LPA did not observe any hazards that raise safety concerns at the time of inspection. There was a working carbon monoxide detector and a smoke detector installed in the room. Fire extinguisher and first aid kit were also observed in the classroom. Cubbies are available in the room for children to store their belongings. Cubbies are labeled individually with children’s name. Children from this room will use bathroom at the B building. A portable sink will be installed by the room for children to wash their hands. COVID-19 precautions were also being taken and followed in the room. Hygiene supplies were available and observed. No changes are being made to outdoor space of both programs and facility will continue to follow the previous restrictions. Facility will be allowed to use portable room # 28 until June 2021 as of today. Fire clearance has been granted by San Rafael Fire Department.

This report and rights to comment and appeal were discussed with facility. This report must be available in the facility for public review. Facility was advised for any additional questions to call Office, M-F, 8AM-5PM at 650-266-8800 . For Rules and Regulations, visit the Website: www.cdss.ca.gov.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020
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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