214002758-7-15-2026-05-CC-CQUO-DVZUWA-20260715155624

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214002758
Report Date: 07/15/2026
Date Signed: 07/15/2026 03:56:42 PM

Document Has Been Signed on 07/15/2026 03:56 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:	MARIN FORMATIVE CHRISTIAN PRESCHOOL		FACILITY NUMBER:	214002758
ADMINISTRATOR/ DIRECTOR:	KAHLA VINSON		FACILITY TYPE:	860
ADDRESS:	2000 LAS GALLINAS AVENUE		TELEPHONE:	(415) 479-4140
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 19	CENSUS: 16	DATE:	07/15/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Kahla Vinson		TIME VISIT/ INSPECTION COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On July 15, 2026 at approximately 10:00am, LPAs Quimbo and Naves, conducted an unannounced, pre-licensing visit. LPAs met with director, Kahla Vinson and explained the purpose of the visit. Present during the visit included 6 staff (including director) and 16 preschool children. LPAs observed all teaching staff are fingerprint cleared. Program is an already licensed preschool program under license number 210102848. Program requested to add a toddler component. Due to the facility requesting an additional age component, a single license has been generated and existing facility number 210102848 will be consolidated to the single license number 214002758. Program is requesting for a total capacity of 60 children: 12 toddlers (18 months to 36 months) and 48 preschool children (2 years to entry into first grade). Fire clearance for 60 children was received January 20, 2026. Hours of operation will be Monday through Friday 7:45am to 5:00pm. Facility includes three classrooms with restrooms, director's office, lobby, kitchen, and art/teacher room. There are four outdoor areas for children's use. Toddler and preschool children's outdoor areas are physically separate from one another. LPAs inspected day care areas for health and safety hazards and measured day care areas. Toddler Indoor measurements are: There is one classroom for the toddler component, the "Koalas". The indoor area contains a total of 642.52 square feet which will accommodate the request for 12 toddler children. (Continue report on page 2...)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

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)

Page: 2 of 6

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: MARIN FORMATIVE CHRISTIAN PRESCHOOL	FACILITY NUMBER: 214002758
	VISIT DATE: 07/15/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued, Page 2...)
Toddler Outdoor measurements are:
There is one toddler outdoor area that is located directly outside the Koala classroom. The outdoor area measures for 784.34 square feet which will not accommodate the request for 12 toddler children. An outdoor rotation waiver will be submitted.

Preschool Indoor measurements are:
There are two classrooms for the preschool component, "Pandas" and "Teddies". The indoor area contains a total of 1,706.82 square feet which will accommodate applicant's request for 48 preschool children.

Preschool Outdoor measurements are:
There are three outdoor areas for the preschool component. The outdoor area contains a total of 5,109.71 square feet which will accommodate the request for 48 preschool children.

Sinks and Toilets:
There are a total of 6 sinks and 5 toilets for toddler and preschool children's use, which will accommodate the request for 60 children.

The child care center was observed to be clean, sanitary and in good repair. A comfortable temperature for children is being maintained. Furniture and equipment were observed to be maintained in good condition. There are sufficient tables and chairs in the classrooms that are age-appropriate. There are rugs in the classroom that were observed to be clean and free of stains. Per director, rugs are vacuumed at least twice a week.

LPAs observed children's restrooms to be in working condition. There are diaper changing tables for diapering children that are within arm's reach to a hand washing sink. LPAs observed diaper changing tables to be equipped with moisture resistant material and the sides of changing tables are at least 3" high. Diapers and wipes will be provided by the program, however, families are able to provide if needed. LPAs observed children's diapers and wipes to be appropriately stored and labeled with children's individual names. LPAs observed garbage bins with tight fitting lids throughout the facility. Sinks accessible to children do not provide water that is warmer than 120 degrees Fahrenheit.
(Continue report on page 3...)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC809 (FAS) - (06/04)

Page: 3 of 6

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: MARIN FORMATIVE CHRISTIAN PRESCHOOL	FACILITY NUMBER: 214002758
	VISIT DATE: 07/15/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued, Page 3...)
Children sleep on cots. Director stated they will consider obtaining floor mats for toddler children. Sheets and blankets are provided by families and are stored away so that they are not touching each other. LPAs observed cots to be appropriately stored when not in use.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at:https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep, as an additional resource. LPA also informed facility representative of the importance of checking for and removing recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Facility is equipped with multiple first aid kids, multiple fully charged fire extinguishers, smoke alarm, and multiple smoke and carbon monoxide detectors. LPAs tested combination smoke and carbon monoxide detectors in each classroom, which were all observed to be working. When medications are on site, they are stored in emergency backpacks that are located in their designated classrooms.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Licensing documents are posted in the lobby of the facility. Children are signed in and out of program with electronic signatures. Per director, sign in and out sheets are maintained for more than 30 days. There is sufficient cubby space for children's personal belongings throughout the facility.
(Continue report on page 4...)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC809 (FAS) - (06/04)

Page: 4 of 6

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: MARIN FORMATIVE CHRISTIAN PRESCHOOL	FACILITY NUMBER: 214002758
	VISIT DATE: 07/15/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued, Page 4...)
Outdoor area for the toddler component is physically separate from the preschool component. Both outdoor areas are fully enclosed and fenced. There is sufficient shade in both outdoor areas. Preschool outdoor area includes a play structure with resilient padding underneath. LPAs did not observe any pools, spas or other bodies of water on site.

Program does not provide a food service at this time. Children's families provide food that is stored in children's individual cubbies. There are cooking projects with staff and children that is prepared in the facility's kitchen and distributed in the classrooms.

Drinking water is available to children through accessible drinking fountains and a water pitcher that is refilled through the kitchen sink. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

LPA reviewed with director, the LIC 311A, Records to Be Maintained at The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

Director was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website athttps://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication

If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process
(Continue report on page 5...)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: MARIN FORMATIVE CHRISTIAN PRESCHOOL	FACILITY NUMBER: 214002758
	VISIT DATE: 07/15/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued, Page 5...)
Director was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Director was reminded that preschool and toddler component children cannot co-mingle with each other and must be kept physically separate. Director was also reminded written authorization from child's authorized representative is required prior to participation in toddler component.

Facility will be approved for a total capacity of 60 children: 12 toddlers (18 months to 36 months) and 48 preschool children (2 years to entry into first grade) when following is complete:
-Submission of outdoor rotation waiver request.
-Management approval of outdoor rotation waiver.
-Centralized Application Bureau (CAB) final approval of application.

Exit interview conducted and report was reviewed with the director, Kahla Vinson.

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC809 (FAS) - (06/04)

Page: 6 of 6