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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 214005019
Report Date: 09/08/2021
Date Signed: 09/14/2021 10:58:54 AM



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
08/23/2021 and conducted by Evaluator Haydee R Caliboso
COMPLAINT CONTROL NUMBER: 05-CC-20210823121125
FACILITY NAME:C.A.M (CFS) MARTIN LUTHER KING (PS)FACILITY NUMBER:
214005019
ADMINISTRATOR:LOMBARDI KELSEYFACILITY TYPE:
850
ADDRESS:610 DRAKE AVENUETELEPHONE:
(415) 339-9310
CITY:MARIN CITYSTATE: CAZIP CODE:
94965
CAPACITY:23CENSUS: DATE:
09/08/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Paula CifuentesTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Record Keeping
INVESTIGATION FINDINGS:
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On 9/8/21 at 10:15am., Licensing Program Analyst (LPA) Haydee Caliboso arrived at thefacility to conduct a closing complaint investigation in response to the above allegation. LPA spoke with Paula Cifuentes. Present during the inspection was the Site Supervisor. There were no children present during the visit.

Based on LPA's gathered information through observations and interviews with staff the agency has investigated the complaint allegation above. The facility failed to report any changes in the plan of operation that affect services to children.The preponderance of evidence standard has been met. The above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22,Division 12 & Chapter 1, are being cited on the attached LIC 9099D.


This report will be kept in the Facility File and will be made available for Public Review upon request. Website for Forms and Regulations: www.ccld.ca.gov. Appeal Rights were provided to the facility. This report and rights to comment and appeal have been discussed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650)266-8864
LICENSING EVALUATOR NAME: Haydee R CalibosoTELEPHONE: (650)266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 05-CC-20210823121125
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 (CFS) MARTIN LUTHER KING (PS)
FACILITY NUMBER: 214005019
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2021
Section Cited
CCR
101212(a)(e)(4)
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101212 (a)(e)(4) Reporting Requirements

(a) Each licensee or applicant shall furnish to the Department reports as required by the Department including, but not limited to, the following:
(e) The items below shall be reported to the Department within 10 working days following their occurrence:
(4) Any changes in the plan of operation that affect services to children. This requirement was not met as evidenced by:

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The program will ensure to report to Community Care Licensing of any changes in the plan of operation that affect services to children.


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Based on observations and interviews the facility failed to report any changes in the plan of operation that affect services to children. Therefore, the above allegations posses a potential Health and Safety risk to children in care.
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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)266-8864
LICENSING EVALUATOR NAME: Haydee R CalibosoTELEPHONE: (650)266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC9099 (FAS) - (06/04)
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