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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108889
Report Date: 09/08/2025
Date Signed: 09/08/2025 03:06:39 PM

Document Has Been Signed on 09/08/2025 03:06 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:C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (SA)FACILITY NUMBER:
210108889
ADMINISTRATOR/
DIRECTOR:		LEYDIS MATAFACILITY TYPE:
840
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 479-2771
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 69TOTAL ENROLLED CHILDREN: 69CENSUS: 69DATE:
09/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:53 PM
MET WITH:Debora OsorioTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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On 9/8/2025 Licensing Program Analysts (LPAs) Naves and Van conducted an unannounced case management visit to the center listed above to address a self-reported Unusual Incident Report (UIR) that occurred on 8/21/25.


The purpose of the inspection was explained, and access to the center was granted. Present today were 0 school-aged children as they are t their school. The center complies with the licensed capacity and limitations.

It was reported to the department that a child was left behind in a classroom on 8/21/25. The staff at Old Gallinas walked to Venetia Valley school to pick up the children for their after-school care. One child was unaccounted for when they returned to the school but were unaware until the child’s parents received a phone call from the school informing them their child was still at the school. The center sent a staff member to go and pick up the child.

LPAs interviewed a staff member present during the incident and both directors and based on the information gathered it was determined that staff did not follow their sign-in and out procedure resulting in the child being left behind.

cont page 2 >>>>
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2025
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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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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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: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (SA)
FACILITY NUMBER: 210108889
VISIT DATE: 09/08/2025
NARRATIVE
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page 2

Due to this latest incident occurring a new process has been implemented. Staff carries a clipboard with sign in and out sheet of children to be picked up. Staff carries green lanyards for children and puts them on the child which has their photos and names and then checks child off sign in and out sheet. Staff take a photo of the sign in and out sheet and are sent to the center for approval to leave the premises. Staff also check the number of green lanyards still in their possession.

A Type B deficiency is issued today.

Additionally, the Director will submit to LPA updated procedure in writing as a Plan of Correction (POC).

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

Appeal rights were given.

Exit interview conducted and report was reviewed with the Director Debora Osorio and Director Diana Gonzalez.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2025 03:06 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 09/08/2025 at 02:40 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: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (SA)
FACILITY NUMBER: 210108889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2025
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. This requirement was not met as evidenced by:
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As a corrective action, the center will submit active supervision training materials, including details of the new implementation and procedures, along with the sign-in attendance of the staff members who participated, to Licensing by September 10, 2025, or earlier, to resolve the deficiency.
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Based on the reviewed records and the interviews conducted, the center did not comply with the section cited above. The staff failed to follow the center's sign-in and sign-out protocol, which resulted in a C1 being left at Venitia School and not being picked up. This was uncovered when Venitia School contacted the family, and the center realized the child was not accounted for. Fortunately, the child was still with Venitia Valley School. This situation poses a potential health and safety risk to the children in care.

• Following the incident, the center’s director met with all staff members, reviewed active supervision practices, and implemented a new transition protocol. As a corrective action, the center will submit active supervision training materials, including details of the new implementation and procedures, along with the sign-in attendance of the staff members who participated, to Licensing by September 10, 2025, or earlier, to resolve the deficiency.
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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.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Jaclyn Naves
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2025


LIC809 (FAS) - (06/04)
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