<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213002658
Report Date: 05/20/2026
Date Signed: 05/20/2026 12:30:37 PM

Document Has Been Signed on 05/20/2026 12:30 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:C.A.M. (CFS) HAMILTON (INF)FACILITY NUMBER:
213002658
ADMINISTRATOR/
DIRECTOR:		BUNTAWAN VAMNUTJINDAFACILITY TYPE:
830
ADDRESS:5520 NAVE DRIVETELEPHONE:
(415) 883-5318
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 22DATE:
05/20/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Director, Buntawan VamnutjindaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On May 20, 2026, at approximately 10:15AM, Licensing Program Analyst (LPA) Nicole Tran conducted an unannounced case management visit at the facility regarding a self-reported incident. LPA met with Director, Buntawan Vamnutjinda, and explained the purpose of the visit. Present during the visit was Director, 9 staff, and 22 children (6 infants and 14 toddlers).

The facility self-reported an incident that occurred on May 12, 2026. Based on the submitted report and interview, a teacher (T1) had brought a child (C1) into a classroom where another teacher (T2) was cleaning in the kitchen. T1 told T2 to watch C1 while they stepped out of the classroom. T2 states they did not hear T1 and did not know C1 was in the classroom. Per staff, C1 was unattended for about 2-3 minutes until other staff realized C1 was in the classroom. C1 was playing with toys and not in distress. The facility informed C1's family of the incident.

A Type “B” deficiency will be cited today due to a child not being under direct visual observation at all times. Director has been proactive in re-training staff in supervision, head count policy, and protocols for transferring active supervision to another staff member. Director has provided LPA proof of training/meeting agenda and supervision procedures.

The facility complied with reporting requirements and has taken appropriate action to investigate and address the incident. The deficiency will be cleared today. Appeal rights were provided.

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

Exit interview conducted and report was reviewed with Director, Buntawan Vamnutjinda.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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)
Page: 2 of 3
Document Has Been Signed on 05/20/2026 12:30 PM - It Cannot Be Edited


Created By: Nicole Tran On 05/20/2026 at 11:57 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) HAMILTON (INF)
FACILITY NUMBER: 213002658

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2026
Section Cited
CCR
101429(a)(1)

1
2
3
4
5
6
7
101429 Responsibility for Providing Care and Supervision for Infants

(a) In addition to Section 101229, the following shall apply:

(1) Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Director has been proactive in re-training staff in supervision, head count policy, and protocols for transferring active supervision to another staff member. Director has provided LPA proof of training/meeting agenda and supervision procedures.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not ensure that direct visual observation was maintained at all times. An infant was without visual observation for approximately 2-3 minutes, which poses a potential health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
Deficiency will be cleared today.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:
Nicole Tran
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
Page: 3 of 3