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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004598
Report Date: 04/11/2024
Date Signed: 04/11/2024 03:30:06 PM

Document Has Been Signed on 04/11/2024 03:30 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 CENTERFACILITY NUMBER:
384004598
ADMINISTRATOR/
DIRECTOR:		CASTILLO, MELISSAFACILITY TYPE:
850
ADDRESS:2050 FOLSOM STREETTELEPHONE:
(415) 401-4253
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 30DATE:
04/11/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Melissa Castillo, Michelle ZertucheTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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On 4/11/2024 at 9:50AM., Licensing Program Analysts (LPAs), Luis Gomez and Gloria Alvarado met with Lead Teacher, Michelle Zertuche. The purpose of the inspection was explained and was for an Unannounced, Annual Random inspection. This facility is licensed to operate a preschool program. Per lead teacher, director is not currently on site. Present was the Lead Teacher and 5 staff supervising 30 children. Director, Melissa Castillo arrived during inspection. The childcare program utilizes two classrooms: (Kai Mi Ching: 3-5 and Rio: 3-5 years old), and one, outdoor play area (Courtyard). LPAs inspected this facility for health and safety hazards.

LPAs observed the following: Classrooms had age-appropriate playthings available for the children. The floor and ground surfaces were clear of obstructions or hazards.

At 10:17AM., Based on record review and observations, LPAs confirmed 4 children present had not been properly signed in.

Classrooms were equipped with tables and chairs, scaled to the size of the children, and individual storage cubbies for children's belongings. Accessible furniture was free of any sharp corners or splinters. The children’s bathrooms were clean, with toilets and fixtures in operating condition. Classroom were equipped with added storage cabinets for materials and supplies.

At 10:33AM., Based on observations and interviews, LPAs confirm accessible cleaning detergents in an unlocked cabinet.

At 10:42AM., Based on observations., LPA observed accessible bag of expandable water beads in the Kai Mi Chig classroom. During inspection, items was removed from classroom. Facility was issued an Advisory Note: Technical Violation (LIC9102TV). (REFER TO 809c, FOR CONT.)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 04/11/2024 03:30 PM - It Cannot Be Edited


Created By: Luis Gomez On 04/11/2024 at 01:13 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
FACILITY NUMBER: 384004598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)
Criminal Record Clearance
(e) 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 is not met as evidenced by:
Deficient Practice Statement
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At 12:27PM., Based on observation, record review, and interviews, LPAs confirmed staff (S5) present without criminal record clearance or association on file. This poses an immediate health and safety risk to children in care.
POC Due Date: 04/12/2024
Plan of Correction
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Director will ensure staff, S5, receives criminal record clearance and association prior to presense with children.
Sign the LIC9224, notice of A-type deficiency form will be stored in children's files.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Marie Rodriguez
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


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Document Has Been Signed on 04/11/2024 03:30 PM - It Cannot Be Edited


Created By: Luis Gomez On 04/11/2024 at 01:13 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
FACILITY NUMBER: 384004598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 10:33AM., Based on observations, LPAs confirm accessible cleaning detergents in an unlocked cabinet. Detergents in cabinet were removed during inspection. This poses a potential health and safety risk to children in care.
POC Due Date: 04/17/2024
Plan of Correction
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Director will ensure cabinets used for storing cleaning supplies/ detergents are made inaccessible by the due date: 4/17/2024.
Proof of correction will be submitted to the department via email.
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 10:17AM., Based on record review and observations, LPAs confirmed 4 children present had not been properly signed in. This poses a potential health and safety risk to children in care.
POC Due Date: 04/17/2024
Plan of Correction
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Director will ensure proper sign-in procedure is review with authorized representatives and staff by the due date: 4/17/2024.
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.
SUPERVISOR'S NAME:Marie Rodriguez
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


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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
FACILITY NUMBER: 384004598
VISIT DATE: 04/11/2024
NARRATIVE
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For scheduled rest/ nap services, each classroom had stackable cots made from a cleanable material. Per staff, napping linens and blankets are washed every week on-site. LPAs reminded director to ensure cots are properly stored, and labeled with children’s names. The facility had adequate ventilation, lighting, and was a comfortable temperature. Facility had a functioning telephone service and fully changed fire extinguishers: 2A:10:BC, located in hallway. Per staff, carbon monoxide detectors are, ‘built-in’.

During inspection, LPAs inspected the outdoor play area (courtyard). Area was completely enclosed, rubber padding installed for added safety. Children’s playthings, and equipment were in like-new condition. The sandbox area was free of hazards or foreign objects. LPAs observed accessible drinking water and shading rest available for the children.

The food preparation area/ food storage was reviewed during inspection. The program provides two snacks, and lunch service, delivered daily by a third-party. The food preparation area was observed clean and free of any trash or rubbish. Prepared food items inspected were current.

At 11:40AM., LPAs reviewed facility records including: 5 children’s files and 5 personnel files. The personnel files were reviewed and contained: Teachers Qualifications; Notice of Employee Rights (LIC9052); Acknowledgement to Report Suspected Child Abuse (LIC9108); and Personnel Record.

LPA reminded facility to ensure staff the 'Mandated Reporter Training’ certificate (AB1207), and required proof of required immunization, stored in the facility files. Facility was issued Advisory Note: Technical Violation (LIC9102TV) during inspection.

At 12:27PM., Based on observation, record review, and interviews, LPAs confirmed staff (S5) present without criminal record clearance or association on file.

Facility’s 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); and Personal Rights (LIC613A).

Facility personnel have Cardiopulmonary Resuscitation / First Aid certifications, set to expire on: 7/2025.


LPA reminded director to conducted and log required emergency disaster drills every six months. (REFER TO 809c, FOR CONT.)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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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
FACILITY NUMBER: 384004598
VISIT DATE: 04/11/2024
NARRATIVE
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(Page 3)
LPAs observed required postings in classroom, included the: License; Notification of Parent’s Rights (PUB394); Passenger Safety Laws (PUB269); Lunch Menu (April, 2024); Outdoor Space Waiver; and Emergency Disaster Plan (LIC610).

LPA referred Director to the Department website regarding Lead: https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information

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/.

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.

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 cited in the areas evaluated according to the Title 22 Division 12 Chap. 1 Ca. Code of Regulations. Exit interview, plan for correction, and facility evaluation report was discussed with Director, Melissa Castillo. Administrator’s signature on this form acknowledges receipt of these documents.


(REFER TO 809c, FOR CONT.)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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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
FACILITY NUMBER: 384004598
VISIT DATE: 04/11/2024
NARRATIVE
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Facility was issued Type “A” violation and was advised to provide a copy of the ‘Facility 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.
All signed LIC 9224, ‘Deficiency and Acknowledgment of Receipt of Licensing Reports; shall be maintained in all children's files.

Facility was issued civil penalty for $300.00.

During inspection, LPAs and Director discussed annual fees due to the department. LPA provided online account access and current statement information to director.

LPA unable to print report during inspection. LPA will email copy of report to facility at a later date.

This report must be made available in the facility for public review. Notice of site visit was given and must remain posted for 30 days. The Regional Manager 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: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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