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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213003961
Report Date: 11/05/2025
Date Signed: 11/05/2025 04:31:40 PM

Document Has Been Signed on 11/05/2025 04:31 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:CITY OF SAN RAFAEL - PARKSIDE CHILDREN'S CENTERFACILITY NUMBER:
213003961
ADMINISTRATOR/
DIRECTOR:		MCGRATH, KELLYFACILITY TYPE:
850
ADDRESS:51 ALBERT PARK LANETELEPHONE:
(415) 485-3388
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 29DATE:
11/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:12 PM
MET WITH:Jackie NewsomTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 11/5/25, Licensing Program Analysts (LPA) Naves conducted a case management inspection and met with the Director, Jackie Newsom and Gaby Farias recreational supervisor. The purpose of the inspection was explained. Present was Director, 6 teachers, and 29 children. The case management was related to deficiencies cited on 9/3/25.

The facility did not comply with staff having current Mandated Reporter certifications and incomplete files. Missing from the files were Immunization (MMR and TDAP) records, TB tests, LIC 9108, LIC 9052 Employee rights, Flu declinations and Lic 503 Health screenings were all missing from staff and director files.

LPA reviewed the staff files and found that 3 staff members were still missing Mandated Reporter Training certificates and 5 staff members still missing Immunization records and health screenings.

LPA has given another due date of 11/12/2025 by end of business today for Mandated Reporter certifications and a due date of 11/25/25 end of business day for immunization records and LIC 503 health screenings.

See 809D for deficiencies cited today.

Exit interview was conducted with Director Jackie Newsom.

The report and Notice of Site Visit was provided.

Notice of Site Visit will be posted for 30 days.

Appeal rights were given.


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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Document Has Been Signed on 11/05/2025 04:31 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 11/05/2025 at 03:31 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: CITY OF SAN RAFAEL - PARKSIDE CHILDREN'S CENTER
FACILITY NUMBER: 213003961

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2025
Section Cited
CCR
1596.8662(b)(1)

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(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
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Director will email Mandated Reporter Training Certificates for herself and for remaining 3 staff . Due date will be 11/12/2025 by end of business day.
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Based on observation and record review, the licensee did not comply with the section cited above in staff and director not having Mandated Reporter Training Certifications, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
11/05/2025
Section Cited
CCR101217(a)

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(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
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Director will email LPA all missing forms for 5 staff members by 5pm on 11/25/25.
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Based on record review, the licensee did not comply with the section cited above in all staff records including directors were all incomplete.Immunization (MMR and TDAP) records, TB test result clearance,LIC 9108, Employee rights, Flu declinations were all missing from staff and director files and Lic 503 Health screening which poses/posed a potential health, safety or personal rights risk to persons 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: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2025


LIC809 (FAS) - (06/04)
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