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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005192
Report Date: 03/28/2024
Date Signed: 03/28/2024 05:19:50 PM


Document Has Been Signed on 03/28/2024 05:19 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:C.A.M. (CFS) -CANAL CHILD CARE CENTER (PS)FACILITY NUMBER:
214005192
ADMINISTRATOR:XIAOLI RODRIGUESFACILITY TYPE:
850
ADDRESS:215 MISSION AVENUETELEPHONE:
(415) 526-7500
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:44CENSUS: 26DATE:
03/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:23 PM
MET WITH:XiaoLi RodriguesTIME COMPLETED:
05:30 PM
NARRATIVE
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On 3/28/2024, Licensing Program Analyst (LPA) Hanson Leong conducted an unannounced case management visit to the Child Care Center (CCC) listed above. The purpose of the visit was to follow up on two self-reported incidents that occurred on 3/15/2024 and 3/19/2024. During the visit, LPA met with the Director, XiaoLi Rodrigues, and explained the purpose of the visit. During the visit, twenty-six preschool-aged children and eight staff members were present. The director and the eight staff members present at the CCC have all received criminal record clearance from the department. The CCC operates within its capacity and in accordance with the required ratio of staff to children.

According to the director, the incident involving a staff member, S1, and a child, C1, on 3/15/2024 was during closing time, and no one was present besides S1 and C1. LPA will wait for more information before closing out this incident.

LPA reviewed the emergency contact information for child, C2, following an incident.that occurred on 3/19/2024 and found that the name of the individual who picked up C2 was not on the emergency contact list. According to the director, staff, S2 was familiar with this individual who picked up C2. According to the director, she observed that the name on the sign-out sheet was not on the emergency pick up list. Based on the interview with the director and the record review of C2, LPA concluded that the facility would receive a Type B deficiency for violating the regulations regarding the emergency pick-up list.

Please refer to LIC 809D for today’s citation.

Appeal Rights were given to the Director, XiaoLi Rodrigues

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

Exit interview conducted and report was reviewed with the Director, XiaoLi Rodrigues.

SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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 03/28/2024 05:19 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: C.A.M. (CFS) -CANAL CHILD CARE CENTER (PS)
FACILITY NUMBER: 214005192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2024
Section Cited
CCR
101221(b)(5)

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101221 Child's Records
(b) Each record shall contain information including, but not limited to, the following:
(5) Name, address and telephone number of the child's authorized representative
This requirement is not met as evidenced by:

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The director stated that she would conduct an all-staff meeting to discuss emergency pick-up information.
Proof of attendance of all staff members is required to correct the deficiency.
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Based on interview and record review, a child was picked by an individual who was not on the emeregency pick up list, which poses a potential health, safety, or personal rights 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: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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