384000227-7-25-2022-05-CC-LGOZ-CGNRUV-20220725132033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384000227
Report Date: 07/25/2022
Date Signed: 07/25/2022 01:20:45 PM

Document Has Been Signed on 07/25/2022 01:20 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:	GOOD SAMARITAN FAMILY RESOURCE CENTER CDC		FACILITY NUMBER:	384000227
ADMINISTRATOR:	T CARIAS/C BLOCK/B DIXON		FACILITY TYPE:	850
ADDRESS:	1294 POTRERO AVENUE		TELEPHONE:	(415) 824-9475
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94110
CAPACITY:	36	CENSUS: 17	DATE:	07/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Melissa Castillo Angelica Torres		TIME COMPLETED:	01:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/25/2022 at 8:30AM., Licensing Program Analyst (LPA), Luis J. Gomez met with Teachers, Angelica Torres. Purpose of the inspection was explained and was for an unannounced; annual random inspection. Present in facility were four staff supervising 17 children. Site Director, Melissa Castillo arrived during inspection. Children present had been properly signed in. Preschool program utilizes one classroom and one outdoor play area. Days and hours of operation are Monday- Friday 8:00AM- 5:45PM. Program operates year-around. LPA inspected facility, indoors and outdoors, for health and safety hazards. At 8:45AM., the following was observed: classroom was clean, orderly, and with age-appropriate playthings available for the children. Floor and ground surfaces were free of obstructions. Furniture inspected was in proper repair. LPA observed individual cubbies for storage of children's belongings. Facility had several child sized tables and several chairs for snack and activities. For napping services, stackable cots were stored in classroom and are properly labeled. Per director, napping supplies are washed weekly. Children’s bathroom was reviewed during inspection. Bathroom had supplies were available for handwashing. Staff bathroom is located separately. LPA reminded director to ensure staff bathroom remains inaccessible during operating hours. Classroom was the proper temperature, with ventilation, and lighting. Outlets had been covered. Facility had functioning telephone service, smoke detector (Built-in), carbon monoxide detector, and one, fully-charged, fire extinguisher (2A:10BC). First aid kit was review during inspection. (REFER TO 809C, FOR CONT.)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

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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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: GOOD SAMARITAN FAMILY RESOURCE CENTER CDC	FACILITY NUMBER: 384000227
	VISIT DATE: 07/25/2022

NARRATIVE

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At 9:10AM., LPA inspected the outdoor play area. Area was completely enclosed with adequate shading available for children. Play structure is anchored and outdoor items inspected are good repair. Rubber padding has been installed around structure to absorb potential falls. Accessible drinking water was available for day-care children. Per director, labeled water bottles are refilled by staff.

At 10:05AM., LPA review the facility records including ten children's files and six personnel files. Staff files were reviewed and included: Required Transcripts and current Mandated Reporter Training Certification (AB1207).

At 11:20AM., Based on record review and interview, LPA confirmed classroom personnel's health screenings (LIC503) are missing from staff file. Advisory Note: Technical Violation (LIC9102TV) was issued.

At 11:35AM., Based on record review and interview, LPA confirmed classroom personnel's proof of required immunization missing from facility files. Advisory Note: Technical Violation (LIC9102TV) was issued.

LPA reminded facility ensure staff's Criminal Record Statement (LIC508); and Notice of Employee Rights (LIC9052) are stored in the facility files.

Children's files reviewed and included: Health History (LIC702); Identification of Emergency Information (LIC700); Consent for Medical Treatment (LIC627); Immunization Record; and Notification of Parent’s Rights (LIC995).

Staff member present had their current CPR (Cardiopulmonary Resuscitation)/ First Aid certification expiring: 7/2023. Per director, emergency drill was last conducted on 5/21/2022. LPA reminded director to log disaster drills conducted.

Required posting were posted and include: Childcare License; Lunch Menu; Notification of Parents Rights (PUB393); Updated Emergency Disaster Plan (LIC610).

Program provides daily snack and lunch service for children. Food items reviewed were current and are properly stored. Children’s on-site medication was reviewed during inspection. (REFER TO 809C, FOR CONT.)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

LIC809 (FAS) - (06/04)

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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: GOOD SAMARITAN FAMILY RESOURCE CENTER CDC	FACILITY NUMBER: 384000227
	VISIT DATE: 07/25/2022

NARRATIVE

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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 Child Care Center. A civil penalty of $100.00 minimum/ day up to $500.00 maximum per day/per person will be assessment if this regulation is violated.

For IMS information see Evaluator Manuel – Regulations Interpretations and Procedures for Child Care Centers Section 101173 and 101226. When an IMS is provided, an updated Plan of Operations that includes IMS must be submitted to the Department. Following information regarding ADA was provided: US Department of Justice (USDOJ) toll- free ADA information line at (800) 514- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Based on today's inspection, no deficiencies were cited in areas evaluated, according the Title 22 Division 12 Ca. Code of Regulations. Exit interview was discussed with Director, Melissa Castillo and signature of this form acknowledges receipt of these documents.

The 'Notice of Site Visit' was provided to director and must remain posted for 30 days.

This report and rights to comment were discussed. This report must be available in the facility for public review. For additional questions, facility was advised to contact the Community Care Licensing Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

LIC809 (FAS) - (06/04)

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