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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108890
Report Date: 07/12/2023
Date Signed: 07/12/2023 03:21:12 PM

Document Has Been Signed on 07/12/2023 03:21 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)-OLD GALLINAS CHILDREN'S CENTER (PS)FACILITY NUMBER:
210108890
ADMINISTRATOR:MARIN, IRISFACILITY TYPE:
850
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 472-1663
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 140TOTAL ENROLLED CHILDREN: 64CENSUS: 53DATE:
07/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Iris MarinTIME COMPLETED:
03:35 PM
NARRATIVE
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On 7/12/2023, Licensing Program Analyst (LPA) Hanson Leong, made an unannounced case management visit to the child daycare facility listed above. The purpose of the visit was to follow up on incident which occurred on 5/24/2023. The incident was regarding supervision and reporting an unusual incident late to the department. The LPA was granted entry by the Director, Iris Marin. The LPA explained the purpose of the visit to the Director. All the individuals listed on the facility’s roster have been granted permission to work or be present in a childcare facility. The LPA observed seventeen staff members supervising fifty-three preschool aged children. Children's capacity and ratio requirements were observed to be in compliance.

During today's visit, LPA and the Director discussed the importance of supervision and incident report submission within seven business days. The Director provided the LPA with the signatures from staff who participated in the online supervision training. The LPA was also provided with an email thread as evidence that the director sent the training to the staff. The LPA requested that her management team talk with her regarding the department's reporting requirements. The LPA will require her management team and herself to submit a statement attesting to the training's completion to provide evidence of the training's completion.

The following Type B violations (potential health, safety, or personal rights risk to children in care.) were cited for today’s visit:
1. CCR 102416.2 Reporting Requirements

(b)The Licensee shall report to the Department any of the events as specified in Health and Safety Code. Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. (C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child."

***See Page 2 for continuation***
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
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 07/12/2023 03:21 PM - It Cannot Be Edited


Created By: Hanson Leong On 07/12/2023 at 01:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (PS)
FACILITY NUMBER: 210108890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2023
Section Cited
CCR
102416.2

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102416.2 Reporting Requirements
(b)The Licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. (C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child."
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The director will provide the LPA with a statement attesting to the training's completion to provide evidence of the training's completion.
Due date for plan of correction is 7/14/2023
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This requirement was not met, as evidenced by the record review. The Licensee failed to report to Community Care Licensing an unusual incident within seven days. Failure to report unusual incidences as required to the Department could present potential health and safety risks to the children.
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Type B
07/12/2023
Section Cited
CCR101229(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 is not met as evidenced by
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The director will provide the LPA with the signatures from staff who participated in the online supervision training. The director is require to provided with an email thread as evidence that the director sent the training to the staff.
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Based on interviews and record review, the Licensee did not ensure proper supervision of of a child, which occured on 5/14/2023 This is a potential risk to children in care.
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Due date for plan of correction is 7/14/2023
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 Oquendo
LICENSING EVALUATOR NAME:Hanson Leong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (PS)
FACILITY NUMBER: 210108890
VISIT DATE: 07/12/2023
NARRATIVE
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Continued, Page 2
2. CCR 101229(a)(1) 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.

***The department may clear all violations after the review of the facilities’ Plan of Correction***

A copy of today’s report, the “Notice of Site Visit,” and their appeal rights were given to Iris Marin. Exit interview conducted and report was reviewed with Iris Marin.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC809 (FAS) - (06/04)
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