210108890-3-12-2020-05-CC-FBTQ-BMMVWX-20200312164839

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210108890
Report Date: 03/12/2020
Date Signed: 03/12/2020 04:48:48 PM

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 (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: 125	DATE:	03/12/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Iris Marin		TIME COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Farhan Bashir-Tariq arrived at the facility unannounced and met site supervisor Iris Marin to conduct a case management inspection today in response to a couple of unusual incidents reports that were submitted by the facility. Facility self-reported the incidents. Present there were 125 children in care with 25 staff. During today’s inspection, LPA spoke to site supervisor, teachers and toured the classroom and outdoor area, where incidents took place.

Incident 1: This incident involving two children , who were dropped off by a van driver at the drop off point in parking lot. There were no teachers there to receive the children and children walked on their own towards the classroom until spotted by a teacher. Teacher brought the kids to classroom and reported the incident to site supervisor. Site supervisor spoke to the van driver, who admitted that he was in rush and asked the children to go to the class on their own. Site supervisor conducted a meeting with staff to discuss the drop off procedure. It was also agreed with the van driver that children will be dropped off to classroom if there were no teachers present at the drop off point. NO deficiency was cited regarding this incident.

Incident 2:

This incident involved a lack of supervision, which resulted in two children being left unattended in the restroom for a few minutes. Teachers took children to use restroom and left two children behind, closing the restroom door. Children stayed in restroom area for a few minutes and then decided to walk out of the restroom towards their classroom. Children at that point were spotted by a teacher working in the hallway, who then brought them back to the classroom.

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SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-Tariq	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020

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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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.-OLD GALLINAS CHILDREN'S CENTER (PS)	FACILITY NUMBER: 210108890
	VISIT DATE: 03/12/2020

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Management and executive staff responded immediately to the occurrence of this incident and spoke to staff to discuss policies and procedures for providing care and supervision to children at all times. Staff involved in the incident received a verbal warning regarding the lack of supervision incident.

As a result, the following Title 22 deficiency is being cited on the following page: See LIC 809D. An exit interview was conducted, and Plan of corrections was reviewed and developed with the Director. Appeal Rights were provided and discussed with the Director. Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit. Facility was advised any additional questions to call Office, M-F, 8AM-5PM at 650-266-8800. Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-Tariq	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020

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.-OLD GALLINAS CHILDREN'S CENTER (PS)	FACILITY NUMBER: 210108890
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/13/2020 Section Cited	1 2 3 4 5 6 7	Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1) 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.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by interviews conducted today and touring the classroom, two children were left unattended without any supervision in the restroom. This poses an immediate health and safety risk to the children in care.	8 9 10 11 12 13 14	A signed document of showing that staff attended the training shall be emailed to LPA. Staff may also do a head count before taking children to restroom so that missing children are spotted at the point.
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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 Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-Tariq	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020

LIC809 (FAS) - (06/04)

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