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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213001036
Report Date: 10/21/2025
Date Signed: 10/21/2025 04:33:22 PM

Document Has Been Signed on 10/21/2025 04:33 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:CITY OF SAN RAFAEL - PICKLEWEED P/SFACILITY NUMBER:
213001036
ADMINISTRATOR/
DIRECTOR:		VELARDE, MARIAFACILITY TYPE:
850
ADDRESS:40 CANAL STREETTELEPHONE:
(415) 485-3101
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 44TOTAL ENROLLED CHILDREN: 44CENSUS: 0DATE:
10/21/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:16 PM
MET WITH:Yessenia Hernandez TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 10/21/2025 Licensing Program Analysts (LPAs) Naves and Van conducted an unannounced case management inspection and met with Yessenia Hernandez (lead teacher) and Gaby Farias Senior Recreation Supervisor via telephone to follow up on an unusual incident reported to the Department. At the time of inspection, no children were present due to school being let out for the day.

The incident was self-reported to the Department on 10/14/2025. The incident occurred on 10/8/2025, involving a child’s hair being pulled by a staff member. The staff member that pulled the child’s hair admitted to having pulled the child’s hair. The intent was to “show her how it feels when she does it to others.”

The teacher was put on administrative leave on 10/9/25 and terminated the following day.

Childs parents were notified and were upset but decided to allow child to remain at facility.

Facility will be conducted as a refresher of being a Mandated Reporter and training will be done to ensure an incident like this does not occur again.

Based on staff interviews and information obtained a deficiency will be cited.

See 809D for deficiencies cited.

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

An exit interview was conducted, and the report and appeal rights were reviewed with Lead Teacher Yessenia Hernandez and Gaby Farias via telephone.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2025
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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Document Has Been Signed on 10/21/2025 04:33 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 10/21/2025 at 03:49 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: CITY OF SAN RAFAEL - PICKLEWEED P/S
FACILITY NUMBER: 213001036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2025
Section Cited
CCR
101223(a)(3)

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101223 Personal Rights (a)The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

This requirment was not met, as evidenced by:
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The center will hold an all-staff training on children’s personal rights on October 27, 2025. The training will include reviewing mandated reporter requirements and the teacher pyramid. Additionally, the staff involved was reprimanded on the same day and was terminated the following day.
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Based on the interview and record review, the Center did not comply with the above regulation. A staff member pulled C1’s hair to demonstrate how it felt when C1 pulled others’ hair. This intention violated the child’s personal rights, which poses a potential health and safety risk to the children in care.
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As part of the plan of correction, the center will submit all training materials and the teachers' attendance confirmations to the Licensing Office. Once received, the deficiency will be cleared.


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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: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2025


LIC809 (FAS) - (06/04)
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