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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384000227
Report Date: 03/03/2026
Date Signed: 03/03/2026 05:25:05 PM

Document Has Been Signed on 03/03/2026 05:25 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 CDCFACILITY NUMBER:
384000227
ADMINISTRATOR/
DIRECTOR:		T CARIAS/C BLOCK/B DIXONFACILITY TYPE:
850
ADDRESS:1294 POTRERO AVENUETELEPHONE:
(415) 824-9475
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 16DATE:
03/03/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Mary Gaston, Lilian Sanchez TIME VISIT/
INSPECTION COMPLETED:
05:35 PM
NARRATIVE
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On 3/3/2026 at 2:30PM., Licensing Program Analyst (LPA), Luis Gomez met with Site Supervisor, Liliana Sanchez. The purpose of today's visit was explained and was for an unannounced- annual/ random inspection. This facility is a licensed preschool program. Present was the Site Supervisor, and 5 staff supervising 16 children. The children present have been signed in by guardians. The facility’s day and hours of operation are Monday- Friday, 8:00AM- 5:30PM. The program utilizes the main classrooms: 2-5 year old, and the outdoor play yard. LPA inspected facility, indoors and outdoors, for health and safety hazards.

At 2:40PM., LPA observed the following: the classroom was neat and orderly, with age-appropriate playthings available for the children. The floor and ground surfaces were clean and clear of obstructions or hazards. The classrooms have labeled cubbies for storage of belongings. The children’s furniture was in good repair and free of sharp corners or splinters. LPA observed tables and chairs were scaled to the appropriate size.

At 2:50PM., Based on observation, LPA confirmed door sweep on door leading to outside area was broken.

The classroom was equipped with several activity areas including the: reading area, math/ science, and dramatic play. The classrooms have added cabinets for teacher supplies and personal items. The facility books, playthings, and learning materials supplies were in like-new condition. The trash bins used for disposal of solid waste are properly covered. The bathrooms were clean with fixtures in operating condition. Per Site Supervisor, trash bins are emptied out daily. The classroom was equipped with a diaper changing tables for the staff. The changing table was observed clean.

For nap/ scheduled rest, the facility has foldable mats available for each child in care. Per site supervisor, the napping supplies (blankets, linens) are washed weekly by guardians. The classrooms had adequate ventilation, lighting, and were maintained at a comfortable temperature. The cleaning detergents, compounds, wipes, spray bottles and other items, which could pose a danger are stored inaccessible to children. The facility had a functioning telephone service; carbon monoxide (CO) detector; and fire extinguisher (2A10BC) near the front door. (REFER TO 809C, FOR CONT.)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2026
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 03/03/2026 05:25 PM - It Cannot Be Edited


Created By: Luis Gomez On 03/03/2026 at 04:41 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: 03/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239(n)
Fixtures, Furniture, Equipment and Supplies
(n) Furniture and equipment shall be maintained in good condition, free of sharp, loose or pointed parts.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 2:50PM., Based on observation, LPA confirmed door sweep on door leading to outside area was broken. This poses a potential risk to the health and safety of children in care.
POC Due Date: 03/13/2026
Plan of Correction
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The Site Supervisor will install new doors sweep on door leading to outside area by due date: 3/13/2026. Proof of correction will be submitted to the Department via email.
Type B
Section Cited
CCR
101238.2(d)(2)
Outdoor Activity Space
(d) The surface of the outdoor activity space shall be maintained: (2) Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 3:00PM., Based on observation, LPA confirmed exposed sharp screws on planter box in the outdoor area. This poses a potential risk to the health and safety of children in care.
POC Due Date: 03/13/2026
Plan of Correction
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The Site Supervisor will remove planter boxes in outdoor area by the due date: 3/13/2026.
Proof of correction will be submitted to the Department via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Luis Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2026


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: 03/03/2026
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(Page 2)
The food preparation/ kitchen area was reviewed during visit. The area was observed clean and free of debris or rubbish. Per site supervisor, food services are provided by third party, ‘Chiefables’ and delivered to site.
During inspection, LPA reviewed the outdoor play yard. LPA observed areas are completely enclosed, with a shaded rest, available for the children.

At 3:00PM., Based on observation, LPA confirmed exposed sharp screws on planter box in the outdoor area.

The play structure was securely anchored with absorbent material (turf) installed underneath. For water services, refillable water bottles are brought to site by the families. The drinking water is available for children to have as they wish.

At 3:35PM., LPA reviewed facility records including samples of 5 children and 6 personnel files. The staff files were reviewed contained: Proof of Teacher Qualification; Personnel Record (LIC501); Notice of Employee Rights (LIC9052); Proof of completed Mandated Reporter Course (AB1207); and Acknowledge to Report Suspected Abuse (LIC9108).

LPA reminded site supervisor, the staff files must include proof of required immunization.

The children’s files were reviewed and included the: Consent for Medical Treatment (LIC627); Identification of Emergency Information; Immunization Record; and the guardian- signed Personal Rights (LIC613A), Notification of Parents Rights (LIC995A) forms.

The director's cardiopulmonary resuscitation/ first aid certification was current, expiring: 7/2027

Per director, facility is performing emergency disaster drills on-site; both the fire and earthquake drill were completed on: 1/14/2026, and 10/16/2025.

The required postings are in lobby and included the: License; Emergency Disaster Plan (LIC610); Notification of Parent’s Rights (LIC995A); Lunch/ Snack Menu (March, 2026); Seat Belt Safety Laws; and Personal Rights. (REFER TO 809C, FOR CONT.)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: 03/03/2026
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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 with director. For IMS information see Evaluator Manuel – Regulations Interpretations and Procedures for Child Care Centers Section 101173 and 101226. When an IMS is provided, an updated Plan of Operations that includes IMS must be submitted to the Department. Following information regarding ADA was provided: US Department of Justice (USDOJ) toll- free ADA information line at (800) 514- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The facility was reminded that all adults 18 and over, 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 Child Care Center. A civil penalty of $100.00 minimum/ day for maximum of 5 days or, if the penalty is repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Based on today's inspection, deficiencies were observed in the areas evaluated according to Title 22, Division 12, Chap. 1 Ca. Health and Safety Code of Regulations and cited on LIC809D. An exit interview and facility evaluation report (FER) was discussed with Site Supervisor, Liliana Sanchez. Site Supervisor’s signature of this form acknowledges receipt of these documents.

This report and rights to comment were discussed. This report must be available in the facility file for public review. The Notice of site visit was provided and must remain posted for 30 days. The site supervisor was advised to ask any additional questions, and may also contact the San Bruno Regional Office, M-F, 8:00am-5:00pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
LIC809 (FAS) - (06/04)
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