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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108890
Report Date: 10/28/2026
Date Signed: 10/28/2026 12:01:11 PM

Document Has Been Signed on 10/28/2026 12:01 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:C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (PS)FACILITY NUMBER:
210108890
ADMINISTRATOR/
DIRECTOR:		LEYDIS MATAFACILITY TYPE:
850
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 472-1663
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 140TOTAL ENROLLED CHILDREN: 140CENSUS: 60DATE:
10/28/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:28 AM
MET WITH:Michelle Fox TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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On October 28,2026 Licensing Program Analyst (LPA) Naves conducted and unannounced Case Management visit. LPA met with the director Michelle Fox and explained the purpose of the visit and entry was granted. 22 staff members including director supervised 60 children. The facility is operating within its capacity and limitations on this day.

The facility self reported 2 Unusual incidents on September 29,2026 and October 22,2026.

The incident reported on September 29,2026 was in regards to an inappropriate interaction with a staff member and a child. The incident from October 22,2026 was regarding another child sustaining an injury while playing.

Based on the information gathered and the review of documentation, and interview, the incident of an inappropriate interaction with staff member and child will result in a deficiency being issued. For the incident with the child being injured during play no deficiency will be cited a refresher guidance was given on supervision.

LPA advised the Director to review staff roles, procedures, and appropriate interactive practices to prevent recurrence.
A Notice of Site Visit was issued and must remain posted for 30 consecutive days.

An exit interview was conducted, and a copy of the report was provided to the Director Michelle Fox.
Ali Zebila
Jaclyn Naves
DATE: 10/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2026
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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Document Has Been Signed on 10/28/2026 12:01 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 10/28/2026 at 10:10 AM
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: 10/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2026
Section Cited
CCR
101223(a)(1)(2)(3)

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101223 Personal Rights(a)(3).. The licensee shall ensure that each child is accorded the following personal rights:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to...
This requirement was not evidenced by:
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Facility put staff member on administrative leave immediately after knowledge of incident and staff member has returned and issued a final written warning and is currently receiving re-training.
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Based on interviews it was found that the facility did not comply with the cited section above it was determined a child in care had been handled in an innapropriate,unnecessary manner by a staff member on,which did not align with safe, supportive, or developmentally appropriate practices. This action posed an immediate health and safety risk to the children in care.
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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.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Jaclyn Naves
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2026


LIC809 (FAS) - (06/04)
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