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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213006108
Report Date: 04/13/2022
Date Signed: 04/13/2022 12:50:31 PM


Document Has Been Signed on 04/13/2022 12:50 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:C.A.M. (CFS) SAN PEDRO (PS)FACILITY NUMBER:
213006108
ADMINISTRATOR:LOMBARDI, KELSEYFACILITY TYPE:
850
ADDRESS:498 POINT SAN PEDRO ROADTELEPHONE:
(415) 485-2450
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:40CENSUS: 23DATE:
04/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ashley Girdler, Alida LeonTIME COMPLETED:
01:05 PM
NARRATIVE
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On 4/13/2022 at 10:05A.M., Licensing Program Analyst, (LPA) Luis J. Gomez met with Lead Teacher, Ashley Girdler and Area Manager, Alida Leon. The purpose of today's inspection was explained and was in response to an incident that had occurred on February 17, 2022. Incident was self- reported by facility management and involved a preschool child leaving the facility classroom (Room B) without teacher supervision. Present was the Lead Teacher, and Area Manager and 5 staff supervising 23 children. All staff had criminal record clearances on file. LPA inspected facility, indoors and outdoors, with director for health and safety hazards.

During the inspection, LPA performed observations, record review, interviewed staff and site director.

During interview with Lead Teacher, it was reported that on 2/17/2022 at 12:40P.M., during classroom transition, day-care child (C1) had left the classroom and onto the outdoor ramp. Per staff, facility was notified by elementary school personnel and child C1, was immediately brought inside. Lead Teacher stated child’s authorized representatives was informed of the incident.

Per director, she had spoken with staff regarding the incident. Safety bell had also been installed on the exit doors and, will remain on during operating hours.

As a result of the occurrence of this incident, a violation of the Title 22 Division 12 of Ca. Code of Regulations was observed, and deficiency was cited on the attached 809D. An exit interview was conducted with Lead Teacher. A copy of this report with the appeal rights was provided, and signature of this form acknowledges receipt of these documents.

Notice of Site Visit for was provided during inspection.

This report must be available in the facility for public review. Director was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
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 04/13/2022 12:50 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: C.A.M. (CFS) SAN PEDRO (PS)
FACILITY NUMBER: 213006108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited

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101229(a)(1) Responsible for providing Care and Supervision: 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. This requirement is not met as evidenced by:
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Based on interviews and record review, LPA confirmed day-care child (C1) left classroom b, without teacher supervision. This poses a potential health and safety risk to children in care.
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Proof of correction will be submitted to LPA via email.

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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: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
LIC809 (FAS) - (06/04)
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