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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210108889
Report Date: 07/22/2025
Date Signed: 07/22/2025 02:19:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 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
06/13/2025 and conducted by Evaluator Jaclyn Naves
COMPLAINT CONTROL NUMBER: 05-CC-20250613083207
FACILITY NAME:C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (SA)FACILITY NUMBER:
210108889
ADMINISTRATOR:LEYDIS MATAFACILITY TYPE:
840
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 479-2771
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:69CENSUS: 33DATE:
07/22/2025
UNANNOUNCEDTIME BEGAN:
11:56 AM
MET WITH:Lexi HallumTIME COMPLETED:
02:37 PM
ALLEGATION(S):
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Staff did not maintain adequate supervision on child, resulting in child being left behind.
Staff did not report incident to department.
INVESTIGATION FINDINGS:
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On July 22, 2025., Licensing Program Analysts (LPAs) Naves and Van conducted an unannounced inspection to finalize this complaint and deliver the findings to the Center. LPAs met with the site director, Lexi Hallum, and assistant director, Debora Osorio. The purpose of the inspection was explained, and entry to the Center was granted. During the inspection, the Education and Inclusion Manager, Alisa Folda, arrived. At the time of inspection, ten teachers supervised 33 school-aged children.

During the investigation, LPAs conducted interviews with teachers, children, and all involved parties, as well as reviewing all relevant documentation. Concerning the allegation that the facility failed to report the incident to the department, it was revealed that the center did not report the occurrence promptly to the licensing department.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 05-CC-20250613083207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (SA)
FACILITY NUMBER: 210108889
VISIT DATE: 07/22/2025
NARRATIVE
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Additionally, it was found that the staff did not maintain adequate supervision of the child, resulting in the child being left without staff acknowledgment. Consequently, the two above allegations were determined to be substantiated.

LPA Naves informed the Director, Lexi Hallum that this report dated July 22, 2025, document(s) a Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Naves informed the Director to provide a copy of this licensing report dated July 22, 2025, that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 05-CC-20250613083207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (SA)
FACILITY NUMBER: 210108889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2025
Section Cited
CCR
101229(a)(1)
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101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.
(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.This requirement was not met as evidenced by ;
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A plan of correction will be submitted to the LPA of implementation of bright wheel as a tracking for children being signed in/out. A designation of meeting area will be reviewed and what children will be given as a reminder they are to go with staff.
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Based on interviews and record reviews the center did not comply with the cited section above. A child was initially accounted for then child unexpectedly separated from the group and fortunately left with his father without any knowledge from any staff.
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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.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 05-CC-20250613083207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (SA)
FACILITY NUMBER: 210108889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2025
Section Cited
CCR
101212(d)(1)(C)
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(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
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Update of procedures will be discussed and then reviewed with site area managers for an implemenation of submission of UIRs. Center will submit new plan to LPA by 7/31/2025
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Based on interviews and record reviews the center did not comply with the cited section above. CCLD was not informed of an unusual incident ocurring.
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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.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC9099 (FAS) - (06/04)
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