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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108890
Report Date: 07/27/2022
Date Signed: 07/27/2022 04:18:34 PM


Document Has Been Signed on 07/27/2022 04:18 PM - It Cannot Be Edited

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.(CFS)-OLD GALLINAS CHILDREN'S CENTER (PS)FACILITY NUMBER:
210108890
ADMINISTRATOR:LOMBARDI, KELSEYFACILITY TYPE:
850
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 472-1663
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:180CENSUS: 80DATE:
07/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Iris MarinTIME COMPLETED:
04:30 PM
NARRATIVE
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On 7/27/2022, Licensing Program Analysts (LPAs) Van and Garcia met with Director Iris Marin. The purpose of today's inspection was explained and is in response to two unusual incidents that were self-reported to the Licensing Department on July 20, 2022. The first incident was regarding a preschool child who had been left alone inside the classroom for approximately 1– 2 minutes. The second incident involved a child with an injury to the cheek area during outdoor play. Present was the Director and 25 staff supervising 80 children.

Regarding the first incident where a child was left alone in the classroom, based on information received, staff member S1 transitioned children from inside the classroom to an outdoor area and did not request additional staff for support. As a result, C1 was left behind in the classroom. When another teacher re-entered the classroom to get water for the children, the teacher observed child C1 alone inside the classroom, reading a book. Per staff, child C1 was left unattended for approximately 1 – 2 minutes. The Director stated that she immediately notified the child's authorized representatives after the incident. All staff involved were given training on Children's Rights, Active supervision/headcount, and met with Human resources. Training agenda, sign-in, and proof of participation forms were submitted to LPA during today's inspection.

Regarding the second incident where a child injured the cheek during outdoor play, the teachers involved or who observed the incident were interviewed. In addition, LPAs evaluated the physical space where the incident occurred and the care and supervision provided by teachers. Based on interviews and relevant information, the child was having a tantrum and hitting themselves with a boombox. The teacher observed and intervened immediately. Staffing and supervision were appropriate on that day. Director stated on the mentioned date. Three teachers were supervising nine children. The facility was in ratio at the time of the incident, and no deficiencies were discovered or occurred on that day.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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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: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (PS)
FACILITY NUMBER: 210108890
VISIT DATE: 07/27/2022
NARRATIVE
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See 809D for deficiency cited for the first incident of a child left alone in the classroom. LPAs have cleared deficiency during the inspection since the Center has addressed the Care and Supervision training with all staff and provided LPAs with agenda/training materials and signatures of staff who attended the training.

An exit interview was conducted, and the report was reviewed with the Director, Iris Marin. Today's report, July 27, 2022, and notice of site visit will be sent to the Director by email by the close of business on July 27, 2022. Confirmation of receipt is required. LPA informed the Director that the site visit notice must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/27/2022 04:18 PM - It Cannot Be Edited

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: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (PS)
FACILITY NUMBER: 210108890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited

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101229(a)(1) Responsible for providing Care and Supervision: No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement is not met as evidenced by:
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Based on interviews and file review, LPAs confirmed that child C1 was left alone inside the classroom for several minutes. This poses a potential health and safety risk to children in care.
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LPAs cleared deficiency during today's inspection.

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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 LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
LIC809 (FAS) - (06/04)
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