210108890-12-6-2019-05-CC-AMAG-BK6UGS-20191224143447

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210108890
Report Date: 12/06/2019
Date Signed: 12/06/2019 12:16:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2019 and conducted by Evaluator Luis Gomez

COMPLAINT CONTROL NUMBER: 05-CC-20191017140556

FACILITY NAME:	C.A.M.-OLD GALLINAS CHILDREN'S CENTER (PS)		FACILITY NUMBER:	210108890
ADMINISTRATOR:	MARTINEZ, ELIZABETH		FACILITY TYPE:	850
ADDRESS:	251 NORTH SAN PEDRO ROAD		TELEPHONE:	(415) 472-1663
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	180	CENSUS: 110	DATE:	12/06/2019
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Director, Iris Marin		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff caused injury to child

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Luis J. Gomez, met with Program Director, Iris Marin, for a complaint inspection of the the above allegation. Purpose of the inspection explained. Present in the facility is the program director and 24 staff supervising 110 preschool children. Facility is within capacity limit of the license on this day. LPA inspected facility with director for health and safety hazards.

During today’s inspection, LPA interviewed staff and performed site observations.

During the course of the investigation, LPA conducted inspections of the facility on 10/23/2019, 12/4/2019 and 12/6/2019 and peforming an evaluations of the supervision of the children. Interviews were conducted with the Quality Control Manager, Staff, Guardians, and children. A review of facility records was also completed, which included children’s records, personnel roster and parent handbook.

(Continuation on 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 05-CC-20191017140556

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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.-OLD GALLINAS CHILDREN'S CENTER (PS)	FACILITY NUMBER: 210108890
	VISIT DATE: 12/06/2019

NARRATIVE

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(Page 2)

Regarding the allegation of facility staff caused injury to child in care. Based on interviews conducted and a facility file review, LPA confirmed facility staff caused minor injury to a child, using a book to perform inappropriate intervention during an altercation. Staff immediately administered first aid to the child, and guardian was notified.

Therefore, based on the information obtained, preponderance of evidence standard has been met, there for the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, section 12 & chapter are being cited on the attached 9099-D.

Exit interview was conducted with director, Iris Marin and a plan of correction was developed.

LPA Gomez observed notice of site visit was posted in the facility.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 05-CC-20191017140556

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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.-OLD GALLINAS CHILDREN'S CENTER (PS)	FACILITY NUMBER: 210108890
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/06/2020 Section Cited CCR 101223	1 2 3 4 5 6 7	101223 Personal Rights. Licensee shall ensure each child is to be accorded (1)...dignity in his/her personal relationships with staff, and other persons (2) ...safe, healthful and comfortable accommodations that meet his/ her needs. This requirement is not met as evidenced by.	1 2 3 4 5 6 7	Director will conduct a training with site staff to review proper intervention techniques, as specified in the facility handbook, and review protocol when assisting children with behavioral needs.
	8 9 10 11 12 13 14	Based on interviews conducted and a files review, LPA confirmed, facility staff caused minor injury to a child, using a book to performing inappropriate intervention during an altercation. This is a potential health and safety risk to children in care.	8 9 10 11 12 13 14	Director will submit training material and sign-in sheet of staff present during training to LPA Gomez by the due date: 01/06/2020.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019

LIC9099 (FAS) - (06/04)

Page: 3 of 3