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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108890
Report Date: 11/08/2023
Date Signed: 11/08/2023 12:44:15 PM


Document Has Been Signed on 11/08/2023 12:44 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
SAN BRUNO CHILD CARE, 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:MARIN, IRISFACILITY TYPE:
850
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 472-1663
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:140CENSUS: 65DATE:
11/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Leydis MataTIME COMPLETED:
12:45 PM
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On 11/8/2023, Licensing Program Analyst (LPA) Hanson Leong, made an unannounced case management visit to the child daycare facility listed above. This facility also operates a school age program under license number 210108889. The LPA was granted entry by the Director, Leydis Mata. The purpose of the visit was to confirm whether that one individual in question is still employed at this facility. The LPA explained the purpose of the visit to Ms. Mata. Present in the facility: Ms. Mata, 28 staff members and 65 preschool aged children. All individuals listed on the facility’s roster have been granted permission to work or be present in a childcare facility. The facility is operating within its capacity and in accordance with the required ratio of staff to children.

According to Ms. Mata, she is unaware of the individual in question's employment at this facility. The LPA met with two staff members, who were also unaware of the individual in question's employment at this facility. The LPA reminded Ms. Mata that this individual is not permitted to be employed in any licensed child care facilities.

Ms. Mata provided the following documents to the LPA during today's visit: LIC 308, LIC 500, LIC 610, Ms. Mata's CPR & First AId Card, Ms. Mata's Preventative Health and Safety Certificate, and Ms. Mata's Child Development Site Supervisor Permit.

No deficiencies were cited today under CCR, Title 22, Div. 12.

A copy of today’s report was given to Leydis Mata. The Notice of Site Visit was given to Leydis Mata and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with Leydis Mata.

SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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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