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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210110895
Report Date: 11/16/2022
Date Signed: 11/16/2022 03:12:36 PM


Document Has Been Signed on 11/16/2022 03:12 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:CITY OF SAN RAFAEL-MARY SILVERIA CHILDREN'S CENTERFACILITY NUMBER:
210110895
ADMINISTRATOR:BRODY, ANGELAFACILITY TYPE:
840
ADDRESS:375 BLACKSTONETELEPHONE:
(415) 485-3190
CITY:SAN RAFAELSTATE: CAZIP CODE:
94915
CAPACITY:85CENSUS: 51DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Kelly AlbrechtTIME COMPLETED:
03:12 PM
NARRATIVE
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On 11/16/2022, Licensing Program Analyst (LPA), Hanson Leong, made an announced case management visit, in conjunction with an annual visit to the Mary Silveria Children's Center. The LPA was granted entry by the Senior Recreation Specialist (SRS), Kelly Albrecht. The LPA explained the purpose of the visit to the SRS. Guardian, the department's system for conducting background checks, has confirmed that all the individuals listed on the facility’s roster have been granted permission to work or be present in a childcare facility. The LPA observed the director and four staff members supervising fifty-one school age children. Children's capacity and ratio requirements were observed to be in compliance,

During this visit, LPA conducted interviews with members of the staff on an Unusual Incident Report that involved supervision. The LPA assessed that there were no problems with supervision based on the interviews that were conducted with the staff. The LPA observed staff monitoring children while they participated in activities outside. Additionally, the LPA saw a staff member accompanying a child to the bathroom the entire time they were there. In addition, the LPA found that the facility did not have any supervisory issues that needed to be addressed. The director handed over a statement that had been drafted to the LPA. The statement included signatures of all staff members and addressed the issue of supervision.

LPA and the director both performed comprehensive inspections of the facility to look for possible threats to health and safety. The facility offers a first aid kit that is completely loaded with everything that is required for the treatment of wounds and other types of injuries. Toys, furnishings, and learning materials in all classes are age appropriate. The LPA made the observation that the playground equipment and outdoor furnishings are in very good shape. The outdoor play structure is surrounded by wood chips, which can cushion any falls that may occur. The LPA noted that there were no bodies of water present at the facility. All poisons, cleaning products, and other potentially harmful substances have been stored in a location that is inaccessible to children. The building is equipped with smoke detectors, carbon monoxide detectors, fire


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SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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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Document Has Been Signed on 11/16/2022 03:12 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CITY OF SAN RAFAEL-MARY SILVERIA CHILDREN'S CENTER

FACILITY NUMBER: 210110895

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Director will submit a copy of her CPR/First AId Certificate with the EMSA sticker to the department.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: CITY OF SAN RAFAEL-MARY SILVERIA CHILDREN'S CENTER
FACILITY NUMBER: 210110895
VISIT DATE: 11/16/2022
NARRATIVE
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extinguishers that are properly charged, centralized smoke alarms, and phones that are in working order. The director has stated that the facility does not house any firearms or other types of weapons.

The LPA observed that the facility posted the required documents. (i.e., license, waivers, notification of parental rights, notification of personal rights, car seat law, emergency disaster plan, and daily activities).

The LPA reviewed the records of five children. All required forms were in the files of the five children.

The LPA reviewed the records of five staff members. All required forms were in the files of the five staff members. A review of the training records of the five staff members reveals that their CPR/First Aid certification are current, but they lack the required Emergency Medical Services Authority (EMSA) sticker, which is required for approved CPR/First-aid providers. The director was informed by the LPA that the facility would be receiving a Type-B violation since none of the staff members have the required EMSA sticker on their CPR/First Aid certification.

The LPA has informed the director that a Plan of Correction would be provided for all Type-B violations. This Plan of Correction will enable the director to correct the violation.

According to the director, the facility satisfies the requirements by carrying out simulations of fire and earthquake drills twice a year, as well as by documenting their results.

The director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.



Incidental Medical Services (IMS) policy was discussed with the director. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
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SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: CITY OF SAN RAFAEL-MARY SILVERIA CHILDREN'S CENTER
FACILITY NUMBER: 210110895
VISIT DATE: 11/16/2022
NARRATIVE
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The LPA encouraged the director to frequently visit the Licensing website at www.ccld.ca.gov for licensing regulations and new updates. The director can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

A copy of this report, the “Notice of Site Visit,”and their appeal rights were given to the SRS.

A Notice of Site Visit must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted, and the report was reviewed with the SRS, Kelly Albrecht

SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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