384000227-1-17-2024-05-CC-LGOZ-CZKT2J-20240117132047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384000227
Report Date: 01/17/2024
Date Signed: 01/17/2024 01:20:56 PM

Document Has Been Signed on 01/17/2024 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
SAN BRUNO CC RO, 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: 20	DATE:	01/17/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Liliana Sanchez		TIME COMPLETED:	01:20 PM

NARRATIVE

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On 1/17/2024 at 8:50AM., Licensing Program Analyst (LPA), Luis Gomez met with Teacher, Gloria Guzman. Purpose of inspection was explained and was for an Unannounced, Annual Random inspection. This facility is licensed to operate a preschool program. Site Supervisor, Lillian Sanchez arrived during inspection. Present was the Site Supervisor and 5 staff supervising 20 children. LPA reminded facility ensure all children present are properly signed in. Advisory Note: Technical Violation (LIC9102TV) was issued. Preschool program utilizes one classroom, and the outdoor play area. LPA inspected facility for health and safety hazards.

At 9:10AM., the following was observed: Classroom was clean and orderly, with age-appropriate materials available. Floor and ground surfaces were clear of obstructions or hazards. Classroom was equipped with cubbies for children's belongings. Accessible furniture, books, art supplies were free of sharp corners or splinters. Facility has child- sized tables and chairs available for seated activities. Children’s bathroom was maintained clean with fixtures in operating condition. Per Director, the staff bathroom is located separately.

At 9:20AM., Based on observations, LPA confirmed accessible laundry detergent container located in the unlocked staff bathroom.

For napping services, LPA observed foldable mats, made from a cleanable material, available in stored in closet. Per site supervision, napping supplies are washed daily. Facility has adequate ventilation and lighting. Outlets and trash bins have coverings installed. Diaper changing table is available for staff. Per site supervisor, area is disinfected after each use. Facility has a built-in smoke detectors, testable carbon monoxide detector, telephone service, and fire extinguishers: 2A:10:BC. LPA reviewed first aid kit during inspection. (REFER TO 809c, FOR CONT.)

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOOD SAMARITAN FAMILY RESOURCE CENTER CDC	FACILITY NUMBER: 384000227
	VISIT DATE: 01/17/2024

NARRATIVE

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(Page 2)
At 9:35AM., LPA inspected the outdoor play area. Area was completely enclosed with a shade rest available for the children. Climbing structures inspected had been properly anchored, with absorbent material installed for added safety. Per Site Supervisor, water services are provided with refillable cups.

LPA reviewed the food preparation area during inspection. The area was clear of trash or rubbish, safety locks installed on accessible cabinets. Per site supervisor, food services are provided by third party vendor.

At 10:00AM., LPA reviewed facility records including: 3 children’s files and 6 personnel files. Staff’s files were reviewed and contained the: Teachers Qualifications and Personnel Record.

LPA reminded director to ensure staff's proof of required immunization and 'Mandated Reporter Training' certifications (AB1207) are stored in the facility records. Advisory Notes: Technical Violations (LIC9102TV) were issued.

Children’s files were reviewed and contained the: Immunization Records, Identification and Emergency Information (LIC700); Notification of Parent’s Rights (LIC995); Personal Rights (LIC613A) and ‘Written Medical Assessments’.

Facility personnel had their updated CPR/ 1^st aid certification on file, expiring on 7/2025.

Site’s emergency disaster drills are conducted every six months, with last drill completed on 11/6/2023.

Required posting had been posted in lobby, including the: Facility License; Notification of Parent’s Rights (PUB394). LPA advised facility to post the ‘Child Passenger Safety Laws’ (PUB269), Updated Menu and Emergency Disaster Plan (LIC610). Advisory Note: Technical Assistance (LIC9102TA) was issued. (REFER TO 809c, FOR CONT.)

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOOD SAMARITAN FAMILY RESOURCE CENTER CDC	FACILITY NUMBER: 384000227
	VISIT DATE: 01/17/2024

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For IMS information see PIN 22-02CCP. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Assembly Bill (AB) 2370, chapter 676, statues 2018 requires all licensed child care centers (CCC’s) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and every five years after the date of the first test.

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21- CCP.

Site Supervisor was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Based on today's inspection, deficiencies were observed in the areas evaluated according to the Title 22 Division 12 Chap. 1 Ca. Code of Regulations and cited on 809D. Exit interview, report and plan of correction was discussed with Site Supervisor, Liliana Sanchez. Signature on this form acknowledges receipt of these documents.

This report must be made available in the facility for public review. Notice of site visit was provided and must remain posted for 30 days. Director was advised any additional questions to call office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 01/17/2024 01:20 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOOD SAMARITAN FAMILY RESOURCE CENTER CDC	FACILITY NUMBER: 384000227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238(g)

(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 9:20AM., Based on observations, LPA confirmed accessible laundry detergent container located in the unlocked staff bathroom. This poses a potential health and safety risk to children in care.
	POC Due Date: 01/22/2024
	Plan of Correction
1 2 3 4	Director will ensure door to staff bathroom/ supply closet, is fixed and area is made inaccessible by the due date: 1/22/2024. Proof of correction will be submitted to department via email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

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