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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210108890
Report Date: 02/13/2020
Date Signed: 02/13/2020 04:18:10 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
01/28/2020 and conducted by Evaluator Farhan Bashir-Tariq
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20200128092112
FACILITY NAME:C.A.M.-OLD GALLINAS CHILDREN'S CENTER (PS)FACILITY NUMBER:
210108890
ADMINISTRATOR:MARTINEZ, ELIZABETHFACILITY TYPE:
850
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 472-1663
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:180CENSUS: 120DATE:
02/13/2020
UNANNOUNCEDTIME BEGAN:
09:40 PM
MET WITH:Iris Marin-LimaTIME COMPLETED:
11:00 PM
ALLEGATION(S):
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Facility failed to properly report an incident to the authorized representative.
Child sustained injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Farhan Bashir-Tariq met with site supervisor, Iris Marin-Lima to conduct a subsequent complaint investigation today 2/13/20. Purpose of the inspection was explained. Present, there were 120 children with 30 staff. During the course of this investigation, LPA made an initial visit on 2/4/20 and a subsequent visit today to interview teachers and Director. As part of this investigation, LPA collected a copy of Children’s Roster, Employee Schedule, Discipline policy and Personnel report. LPA interviewed teachers S4,S5,S6 and Director regarding the above allegations previously on 2/4/20 and today. LPA also called parents of the child involved to verify the time, they were notified by the school but did not get an answer or call back. Based on the information available after investigation, interviews, and record reviews, although incidents occurred at the day care, but it did not give an indication that incident occurred due to lack of supervision and staff did not inform authorized representative in a timely manner.






Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2020
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 2
Control Number 05-CC-20200128092112
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: 02/13/2020
NARRATIVE
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This agency has investigated the complaint alleging the allegations above. Based on the information obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report and rights to comment and appeal were discussed with Director. 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.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2