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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210108889
Report Date: 06/24/2025
Date Signed: 06/24/2025 01:37:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2025 and conducted by Evaluator Jaclyn Naves
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20250324095448
FACILITY NAME:C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (SA)FACILITY NUMBER:
210108889
ADMINISTRATOR:LEYDIS MATAFACILITY TYPE:
840
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 479-2771
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:69CENSUS: 40DATE:
06/24/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Debora OsorioTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Child was asked to leave classroom.
Child left unsupervised.
INVESTIGATION FINDINGS:
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On June 24, 2025., Licensing Program Analysts (LPAs) Naves and Van conducted an unannounced complaint investigation and met with the Assistant Director, Debora Osorio. The purpose of the inspection was explained, and entry to the facility was granted.During the investigation, LPAs conducted a physical inspection of the facility, interviewed both children and teachers, and reviewed relevant documentation.
Based on the available information, the above allegations were determined to be substantiated, and deficiencies were issued.

LPA Naves informed the Assistant Director, Debora Osorio that this report dated June 24, 2025, document(s) a Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

cont pg 2 >>>>
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 05-CC-20250324095448
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (SA)
FACILITY NUMBER: 210108889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2025
Section Cited
CCR
101223(a)(2)
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101223 Personal Rights (a)The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement has not been met as evidenced by:

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All center staff must review and complete refresher training on children's personal rights, as outlined in Title 22 of the regulations. After finishing the training, detailed documentation of the topics covered and staff attendance will be sent to Licensing by the specified plan of correction deadline.
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Based on interviews and a review of records, the center did not comply with the cited section above. C1’s teacher suggested that, since C1 was reluctant to stay in class, they could leave the classroom. This suggestion led C1 to leave the classroom on their own, which poses an immediate health and safety risk to children in care.
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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.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 05-CC-20250324095448
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (SA)
FACILITY NUMBER: 210108889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2025
Section Cited
CCR
101229(a)(1)
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101229 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary to meet the children's needs. (1)No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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All center staff must review and complete refresher training on active supervision in accordance with Title 22 regulations. After finishing the training, detailed documentation of the topics covered and staff attendance will be sent to Licensing by the specified plan of correction deadline of July 24,2025.
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Based on interviews and a review of records, the center did not comply with the cited section above. C1 left the classroom and was found unsupervised in the school hallway.
This poses a potential health, safety, or personal rights risk to children in care.

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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.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 05-CC-20250324095448
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (SA)
FACILITY NUMBER: 210108889
VISIT DATE: 06/24/2025
NARRATIVE
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page 2

Also, LPA Naves informed the Assistant Director to provide a copy of this licensing report dated June 24, 2025 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

An exit inspection was conducted with the Assistant Director, Debora Osorio.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4