<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384000958
Report Date: 12/15/2021
Date Signed: 12/15/2021 11:55:08 AM

Document Has Been Signed on 12/15/2021 11:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FAMILY SCHOOL CDC BERNAL GATEWAY, THEFACILITY NUMBER:
384000958
ADMINISTRATOR:HAYNES, MARILYNFACILITY TYPE:
830
ADDRESS:3101 MISSION STREETTELEPHONE:
(415) 550-4178
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 16TOTAL ENROLLED CHILDREN: 16CENSUS: 10DATE:
12/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Patricia BacceraTIME COMPLETED:
12:00 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 12/15/2021 at 9:50A.M. Licensing Program Analyst (LPA) Luis J. Gomez conducted an unannounced case management inspection and met with Program Director, Patricia Baccera. This report is to cite a deficiency observed during today's Case Management inspection. LPA inspected facility with director for health and safety hazards.

At 8:55A.M., Based on observations and file review, LPA confirmed staff member, S1, present in day-care without proper criminal record clearance or association on file.

Based on inspection, a deficiency was observed in the areas evacuated and cited according the Title 22 Division 12 of Ca. Code of Regulations and listed on the 809- D. An exit interview was conducted with Director and plan of correction was discussed. A copy of this report with the appeal rights was provided, and signature of this form acknowledges the receipt of these documents.

Type “A” violation was issued today. Director was advised to provide a copy of the Evaluation Report and all Type “A” Deficiencies cited, to parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 (Deficiency and Acknowledgment of Receipt of Licensing Reports) shall be maintained in all children's files.

A civil penalty of $100 was assessed.

Notice of site visit was observed to be posted and shall remain posted for 30 days.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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 2
Document Has Been Signed on 12/15/2021 11:55 AM - It Cannot Be Edited


Created By: Luis Gomez On 12/15/2021 at 11:05 AM
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: FAMILY SCHOOL CDC BERNAL GATEWAY, THE
FACILITY NUMBER: 384000958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2021
Section Cited
CCR
101170(e)(2)

1
2
3
4
5
6
7
101170(e)(2) Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Program Director will ensure staff member, S1, has received proper criminal record clearance and association by the due date: 12/16/2021.
8
9
10
11
12
13
14
Based on observations, file review and interviews, LPA confirmed staff member, S1, present without proper criminal record clearance or association on file. This poses an immediate health and safety risk to children in care.
8
9
10
11
12
13
14
Proof of correction will be submitted to the Department via email.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Cindy Interiano
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2