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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102848
Report Date: 11/05/2025
Date Signed: 11/05/2025 01:09:44 PM

Document Has Been Signed on 11/05/2025 01:09 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:MARIN FORMATIVE CHRISTIAN PRESCHOOLFACILITY NUMBER:
210102848
ADMINISTRATOR/
DIRECTOR:		KAHLA VINSONFACILITY TYPE:
850
ADDRESS:2000 LAS GALLINAS AVENUETELEPHONE:
(415) 479-4140
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 19DATE:
11/05/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:47 AM
MET WITH:Lonnie McHaleTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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On 11/5/2025, Licensing Program Analyst (LPA) Naves conducted an unannounced annual visit and met with teacher Lonnie McHale. LPA explained the purpose of the visit .

19 preschool-aged children and 5 staff members were present during the visit. All 5 of the staff members received criminal record clearance from the department. The facility is within its capacity limits and ratios for today’s visit.

The centers hours of operation are Monday-Friday 7:45 am-5:00pm

LPA observed that all required documents, such as the facility license, waivers, notification of parents’ rights, personal rights, car seat laws, emergency disaster plan, and daily activities schedule, were displayed and visible to the public.

The most recent emergency disaster drill was conducted on 9/17/25, and the LPA observed that it was properly documented.

The LPA observed that the center maintains a record of the children's attendance through a mobile App Bright wheel with corresponding parental signatures, and all enrolled children are accounted for during the day. LPA reminded staff member to ensure parents are signing in with full complete legal name.



The center provides a first aid kit containing all necessary wound care supplies and other injuries. The LPA observed that the classrooms were equipped with age-appropriate toys, furniture, and educational materials.
cont pg 2 >>>>
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: MARIN FORMATIVE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 210102848
VISIT DATE: 11/05/2025
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LPA toured the outdoor area and observed that the equipment and furniture in the outdoor playground appeared to be in excellent condition. The outdoor playground has a fence at least four feet high.The outdoor play area is divided into 2 sections, one for the younger children and one for the older children. LPA observed artificial turf, sand and wood chips in the play areas to absorb any falls. No bodies of water, such as pools or spas, were on site.

The LPA toured the indoor area and found that the building has smoke detectors, carbon monoxide detectors, properly charged fire extinguishers, centralized smoke alarms, and operational phones. According to the director, no firearms or other weapons are kept in the center.

LPA observed that the 2 classrooms (Pandas and Koalas) both had age-appropriate toys, furniture, educational materials, and designated storage space for each child. Electrical outlets were observed to have child safety covers or child tamper-proof locks. One classroom has a diaper-changing table that is not within arm’s reach of a sink, LPA reminded staff member changing tables must be within arm’s reach of a sink and requested it be moved. The bathrooms were found clean and fully operational. The toilets and handwashing facilities were well-kept, safe, and clean. The facility was clean, safe, sanitary, and in good repair.

Disinfectants, cleaning solutions, poisons, and other items that could pose a danger were stored in areas inaccessible to the children. All accessible cabinets and drawers in the classrooms were found to be free of hazardous materials or poisons.

The LPA observed a designated area intended for children to sleep or rest quietly. The area was found to be equipped with sufficient sleeping mats and cots for each child, and these sleeping mats and cots were stored in an appropriate location. Bedding is sent home weekly for washing.



cont pg 3 >>>>
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
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: MARIN FORMATIVE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 210102848
VISIT DATE: 11/05/2025
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The preschool program does not provide lunches for the children. LPA observed that each child had their lunches in their designated storage space.

The LPA reviewed the records of both the children and staff members. The LPA reviewed the files of 6 children and confirmed that their admission agreement, Personal Rights Identification and Emergency Information, Physician's Report, Notification of Parents' Rights, and Consent for Emergency Medical Treatment were included in their records. The LPA reviewed the records of the five staff members and confirmed that they were certified in Pediatric First Aid/CPR and Mandated Reporter and all required licensing forms and immunizations were all current.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP).

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Director was reminded that all adults 18 and over, 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.

cont pg 4 >>>>
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: MARIN FORMATIVE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 210102848
VISIT DATE: 11/05/2025
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LPA discussed the safe sleep regulations with staff and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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

Staff was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.
To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

No deficiencies were cited today under CCR, Title 22, Div. 12.
A Notice of Site Visit was given and must remain posted for 30 days.
LPA reminded staff member of past due licensing fees being due.
Exit interview conducted and report was reviewed with teacher Lonnie McHale.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC809 (FAS) - (06/04)
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