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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108890
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:11:36 PM


Document Has Been Signed on 02/29/2024 02:11 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:LEYDIS MATAFACILITY TYPE:
850
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 472-1663
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:140CENSUS: 65DATE:
02/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Leydis MataTIME COMPLETED:
02:15 PM
NARRATIVE
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On 2/29/2024, Licensing Program Analyst (LPA) Hanson Leong conducted an unannounced case management visit to the child care center listed above. This facility also operates a school-aged program under license number 210108889. The purpose of the visit was to investigate an incident that occurred on 1/29/2024 involving a child (C1) and a staff member (S1). During today’s visit, the LPA met the Director, Leydis Mata. The director was informed of the reason for today's visit by the LPA. During today's visit, sixty-five preschool-aged children were present in the center. Present in the center with fingerprint clearance included the director and twenty-seven staff members. The center is operating within its capacity and in accordance with the required ratio of staff to children.

Following the incident, S1 was placed on administrative leave by the licensee's Human Resources (HR) Department. Although HR offered S1 the option to return to the facility, S1 chose to work at another Community Action Marin facility instead.

Two staff members witnessed the incident and shared consistent information with HR regarding the violation of the child's personal rights. As a result, the department will cite the facility for a deficiency in violating the child's personal rights.

Please refer to LIC 809D for today’s citation.
A copy of today’s report and the center’s appeal rights were given to Leydis Mata.
A Notice of Site Visit was given and must remain posted 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: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/29/2024 02:11 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
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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
CCR
101223(a)(3)

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(a) The licensee shall ensure that each child is accorded the following personal rights:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a
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The HR department will be required to submit supporting information that they gathered during their investigation. The staff members who were involved in this incident must receive training on children’s personal rights and mandated reporter. The licensee must submit training on

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This requirement was not met as evidenced by:
Based on the investigation conducted by the licensee's HR department, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to children in care.
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personal rights and mandated reporting, including staff signatures, to the department by the above due date

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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: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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