384000227-2-27-2025-05-CC-LGOZ-DEB34Q-20250227165530

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384000227
Report Date: 02/27/2025
Date Signed: 02/27/2025 04:55:38 PM

Document Has Been Signed on 02/27/2025 04:55 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:	GOOD SAMARITAN FAMILY RESOURCE CENTER CDC		FACILITY NUMBER:	384000227
ADMINISTRATOR/ DIRECTOR:	T CARIAS/C BLOCK/B DIXON		FACILITY TYPE:	850
ADDRESS:	1294 POTRERO AVENUE		TELEPHONE:	(415) 824-9475
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94110
CAPACITY: 36	TOTAL ENROLLED CHILDREN: 36	CENSUS: 17	DATE:	02/27/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Monica Menjavar, Mary Gaston		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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On 2/27/2025 at 12:45PM., Licensing Program Analyst (LPA), Luis Gomez met with Teacher, Monica Menjavar. The purpose of today's visit was explained and was for an unannounced, annual random inspection. Director, Mary Gaston arrived during inspection. This facility is licensed to operate a preschool-age program. Present was Director and 5 staff supervising 17 children. The days and hours of operation are Monday- Friday, 8:00-5:30PM. Staff in facility have criminal record clearances on file. Children present had been signed in. Program utilizes one classroom and one, shared, outside play area. LPA inspected facility, indoors and outdoors, for health and safety hazards.

At 12:55PM., LPA observed the following: Classroom was neat, with age-appropriate materials and playthings available for the children. Floor and surfaces were clean and clear of obstructions for hazards. Classroom was equipped with tables, chairs, and labeled cubbies for storage of belongings. All furniture inspected was scaled to the appropriate size. The children’s bathroom was clean with supplies available for handwashing. Toilets and faucets inspected were in operating condition.

At 1:00PM., Based on observations, LPA confirmed loose water faucet in children's hand washing area.

LPA observed several closets and added storage areas. LPA remind director to ensure storage closets remain inaccessible. The kitchen/ storage areas were free of any liter/ rubbish, and all food items reviewed were current and properly stored.

For scheduled rest/ nap services, LPA observed foldable, plastic- covered mats available. Per director, blankets and supplies are washed weekly by families. (REFER TO 809C, FOR CONT.)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

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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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: GOOD SAMARITAN FAMILY RESOURCE CENTER CDC	FACILITY NUMBER: 384000227
	VISIT DATE: 02/27/2025

NARRATIVE

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(Page 2)
Facility has adequate ventilation; lighting; and was a comfortable temperature. Facility had a functioning telephone service and fire extinguishers (2A10BC) and testable carbon monoxide detector.

At 1:40PM, LPA reviewed the outside play area. LPA observed absorbent rubber padding /turf installed around climbing structure. Area was completely enclosed with available shading available. The climbing structure was observed properly anchored

LPA observed waste water and broken sink in the outdoor area. Waste water and sink was removed during inspection. Advisory Note: Technical Violation (LIC9102TV) was issued.

Water services are provided with bottles, refilled by staff for children to have water as they wish.

At 2:30PM., LPA reviewed facility records including a sample of the children files and personnel files. Children’s files were reviewed and contained the: Identification and Emergency Information (LIC700); Notification of Parent’s Rights (LIC995); Consent for Emergency Medical Treatment (LIC627); Immunization Record; and Personal Rights (LIC613A).

The personnel files reviewed contained Teacher's Proof of Qualifications; Notice of Employee Rights (LIC9052); and Personnel Record.

At 3:20PM., Based on record review, LPA confirmed staff's proof of immunization and mandated reporter training certifications missing from facility records. Advisory Note: Technical Violation (LIC9102TV) was issued.

Staff's Cardiopulmonary Resuscitation / First Aid certification was current, expiring on: 10/2025.
Facility emergency disaster drill (Fire and Earthquake) was completed on: 1/20/2025 and 11/12/2024. LPA reminded director to ensure drills are logged.

Required postings including the: Facility License; Notification of Parent’s Rights (PUB394); Personal Rights (LIC613A); The Passenger Safety Laws (PUB269); Food Menu (February 2025); and Emergency Disaster Plan (LIC610). (REFER TO 809C, FOR CONT.)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOOD SAMARITAN FAMILY RESOURCE CENTER CDC	FACILITY NUMBER: 384000227
	VISIT DATE: 02/27/2025

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Assembly Bill (AB) 2370, chapter 676, statues 2018 requires all licensed childcare centers (CCC’s) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and every five years after the date of the first test.

LPA has verified that lead testing procedure was completed in accordance with the Written Directives outlined in PIN 21-21- CCP.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, an updated 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 are available at: https://www.ada.gov/resources/child-care-centers/.

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-carelicensing/subscribe and select the Child Care option to receive email communication.

Based on today's inspection, deficiencies were observed in the areas evaluated according to the Title 22 Division 12 Chap. 1 Ca. Code of Regulations and cited on 809D. An exit interview discussing facility evaluation report and plans of correction was conducted with Director, Mary Gaston and Lead Teacher, Monica Menjavar. Director’s signature on this form acknowledges receipt of these documents.

This report must be made available in facility for public review. Notice of site visit was provided and must remain posted for 30 days. Teacher was advised, any additional questions/ concerns to contact the office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/27/2025 04:55 PM - It Cannot Be Edited

Created By: Luis Gomez On 02/27/2025 at 04:29 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: GOOD SAMARITAN FAMILY RESOURCE CENTER CDC	FACILITY NUMBER: 384000227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238(a)

(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 1:00PM., Based on observations, LPA confirmed loose water faucet in children's hand washing area. This poses a potential health and safety risk to children in care.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	Facility will fix loose water faucet in children hand washing area by the due date: 3/14/2025. Proof of correction will be submitted to Department via email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Marie Rodriguez

LICENSING EVALUATOR NAME:

Luis Gomez

LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC809 (FAS) - (06/04)

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