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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108890
Report Date: 04/13/2026
Date Signed: 04/13/2026 11:26:07 AM

Document Has Been Signed on 04/13/2026 11:26 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (PS)FACILITY NUMBER:
210108890
ADMINISTRATOR/
DIRECTOR:		LEYDIS MATAFACILITY TYPE:
850
ADDRESS:251 NORTH SAN PEDRO ROADTELEPHONE:
(415) 472-1663
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 140TOTAL ENROLLED CHILDREN: 140CENSUS: 74DATE:
04/13/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:Diana GonzalezTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
NARRATIVE
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On April 13, 2026, Licensing Program Analyst (LPA) Naves conducted a case management inspection and met with the site supervisor, Diana Gonzalez. The purpose of the inspection was explained. Present was Director and 30 teachers supervising 74 preschool age children. The case management visit was related to the unusual incident report that was self reported and submitted to the department Via telephone call on 3/20/26 which occurred at the facility on 3/20/26.

The incident that reported was that a child was left behind in the play yard after transitioning from outdoor time to indoor time.

Based on information obtained during the inspection, it was found that a child was left behind for approximately 5 minutes and went unnoticed twice. First time staff and group of children entered classroom and 2 children ran inside and began jumping on tables. Staff entered with all children except for 1 to assist in getting children off tables and closed the door once they entered. 1 staff member came back out again to gather water bottles and did not notice child was outside in yard. Another staff member from another class passing by noticed child and knocked to confirm child belonged to classroom and returned child.

Facility conducted a retraining of staff and issued a written warning to all staff members from classroom. Facility has implemented a new protocol for 3 staff members being actively present and assisting during transition times. Staff members have also been assigned specific break times and lunches to prevent a staff member from being unavailable during transition times. Director provided LPA with copies of Corrective action/Disciplinary forms with all staff signatures acknowledgments.

See 809D for deficiencies cited today.
The report and Notice of Site Visit were provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
Exit interview was conducted with Director Diana Gonzalez.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2026
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 04/13/2026 11:26 AM - It Cannot Be Edited


Created By: Jaclyn Naves On 04/13/2026 at 10:48 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: C.A.M.(CFS)-OLD GALLINAS CHILDREN'S CENTER (PS)
FACILITY NUMBER: 210108890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2026
Section Cited
CCR
101229(a)(1)

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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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The center will conduct a meeting with staff and retrain staff on the importance of active supervision at all times. Center has issued written warnings to all staff in classroom and provided LPA with signed acknowledment from staff and has implemented specific break and lunch times to each staff in classroom. Director will submit plan to LPA by end of business day April 17,2026. LPA also informed director additional drop in visits will continue to be necessary.
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Based on observations file review,and interviews, the center did not comply with the section cited above. The center did not provide sufficient supervision; child was left behind for approximately 5 minutes and went unnoticed twice. The center failed to provide adequate supervision to meet the needs of children in care this poses a potential health and safety risk for 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.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Jaclyn Naves
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
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