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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108890
Report Date: 08/27/2020
Date Signed: 08/31/2020 10:38:14 AM

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:MARIN-LIMA, IRISFACILITY TYPE:
850
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 472-1663
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:180CENSUS: 11DATE:
08/27/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Paula CifuentesTIME COMPLETED:
03:40 PM
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*****This report was prepared in Regional Office of San Bruno due to COVID-19. Facility inspection was conducted on 8/27/20. *****

Licensing Program Analysts (LPAs) Farhan Bashir-Tariq and Haydee Caliboso arrived at the facility unannounced to conduct a case management inspection and met with Director, Iris Marin and Quality Support Manager, Paula Cifuentes. Purpose of inspection was explained and was to review Room 5 for health and safety hazards. Present there were 11 children in care with 3 teachers. Facility is a combination center with school age program operating on the other side. Facility is requesting Room 5 from schools age program to be used for preschool program temporarily due to COVID-19 until June 11, 2021.

LPAs observed the room for health and safety hazards. LPAs did not observe any hazards that raise safety concerns at the time of inspection. There was a working carbon monoxide detector and a smoke detector installed in the room. Chemicals were stored in cabinets locked or inaccessible from children. Electric outlets in the room were secured with safety covers. Facility will be allowed to use the room for their preschool program temporarily until June 11, 2021. There were no changes made to outdoor space of both programs and facility will continue to follow previous restrictions.

This report and rights to comment and appeal were discussed with facility. This report must be available in the facility for public review. Facility was advised for any additional questions to call Office, M-F, 8AM-5PM at 650-266-8800 . For Rules and Regulations, visit the Website: www.cdss.ca.gov.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2020
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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