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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213001939
Report Date: 11/19/2025
Date Signed: 11/19/2025 03:24:35 PM

Document Has Been Signed on 11/19/2025 03:24 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) HAMILTON (PS)FACILITY NUMBER:
213001939
ADMINISTRATOR/
DIRECTOR:		ALIDA LEONFACILITY TYPE:
850
ADDRESS:5520 NAVE DRIVETELEPHONE:
(415) 883-5232
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 60TOTAL ENROLLED CHILDREN: 38CENSUS: 35DATE:
11/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:03 PM
MET WITH:Director, Stefanie EavesTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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On November 19, 2025 at approximately 2:00PM case management visit to the facility in regards to an unusual incident that was self-reported to the department on November 12, 2025.

LPA met with Site Supervisor (S1), Stefanie Eaves, and explained the purpose of the visit. Present during LPA's visit included 12 staff supervising 38 preschool age children.

The self-reported incident occurred on November 12, 2025 in the Gazebo Park and Garden Park area. The child’s (C1) class was sitting and waiting in front of the gazebo to transition to Garden Class. One staff member (S2) was attending to a child, another staff member (S3) was supervising the group while tidying up, and the third staff member (S4) was putting equipment away while doing a sweep of Gazebo Park. In their peripheral vision, S4 noticed a child running away from the group. S4 quickly turned to see where the child went but lost sight of them. Staff realized it was C1 and quickly began looking for them. C1 was found in the Garden Park Area after approximately 1-2 minutes. Staff informed C1's authorized representative of incident.

S1 has implemented facility procedures to prevent situations like this from happening again. The Garden Park is separated from the Gazebo Park by a fence with a clasp on it. Per S1, C1 was able to enter the Garden Park area because another program had not closed the fence. S1 has reached out to the other program to remind them to ensure the fence is always properly closed. C.A.M. has also conducted active supervision training with S2, S3, S4 and will adding another teacher to C1’s class to increase supervision. A plan is also being developed with C.A.M. and C1’s family to better support them.

Continued on Page Two
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2025
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: C.A.M. (CFS) HAMILTON (PS)
FACILITY NUMBER: 213001939
VISIT DATE: 11/19/2025
NARRATIVE
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Page Two

Facility is being issued a Type B citation for the self-reported incident due to a child being left without supervision. Appeal rights were provided during today's visit.

S1 was active in implementing facility protocols to ensure supervision is being maintained. Deficiency issued today is also being cleared today's date.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Site Supervisor, Stefanie Eaves.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2025 03:24 PM - It Cannot Be Edited


Created By: Nicole Tran On 11/19/2025 at 03:18 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) HAMILTON (PS)
FACILITY NUMBER: 213001939

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2025
Section Cited
CCR
101229(a)(1)

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(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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Facility has conducted active supervision training with staff and sent LPA the training details and signed agenda from staff who attended. Facility will also be adding another teacher to C1's class to increase supervision needs.
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Based on record review and interview, the Licensee did not comply with the above by leaving a child without supervision in the outdoor activity area. This posed a potential health, safety, and personal rights risk to persons in care.
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Deficiency cleared.

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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:
Nicole Tran
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2025


LIC809 (FAS) - (06/04)
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