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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213003961
Report Date: 03/28/2024
Date Signed: 03/28/2024 11:02:46 AM

Document Has Been Signed on 03/28/2024 11:02 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CITY OF SAN RAFAEL - PARKSIDE CHILDREN'S CENTERFACILITY NUMBER:
213003961
ADMINISTRATOR:MCGRATH, KELLYFACILITY TYPE:
850
ADDRESS:51 ALBERT PARK LANETELEPHONE:
(415) 485-3388
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 36DATE:
03/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Jackie NewsomTIME COMPLETED:
11:17 AM
NARRATIVE
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On 3/28/2024, Licensing Program Analyst (LPA) Hanson Leong conducted an unannounced case management visit to the Child Care Center (CCC) listed above. The purpose of the visit was to follow up with a self-reported incident involving a child (C1), which occurred on 3/19/2024. During the visit, LPA met with the Director, Jackie Newsom, and explained the purpose of the visit. During the visit, thirty-six preschool aged children and six staff members were present. The director and the six staff members present at the CCC have all received criminal record clearance from the department. The CCC operates within its capacity and in accordance with the required ratio of staff to children.

Based on the Unusual Incident Report and the interview with the director, C1 was left in a classroom unsupervised for approximately five minutes. The director stated that she met with the staff on the same day of the incident regarding the lack of supervision involving C1.

After reviewing the Unusual Incident Report and interviewing the Director, LPA concluded that the facility was in violation of regulations specifically due to a lack of supervision.

LPA reminded the director to promptly provide a copy of this licensing report, dated 3/28/2024, that details any Type A citations to the parents or guardians of all currently enrolled children by the next business day or the next day the children are in care. This report must also be shared with the parents or guardians of any newly enrolled children for a period of 12 months from the date of this report. The deadline for providing this information is the next day, 3/29/2024, when the children are in care. For verification purposes, the child's file should include either a signed Acknowledgement of Receipt of Licensing Report (LIC 9224) or another form of written statement.

Please refer to LIC 809D for today’s citation.

Appeal Rights were given to the Director, Jackie Newsom.

Both a Notice of Site Visit and the LIC 809D were given and both must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director, Jackie Newsom

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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Document Has Been Signed on 03/28/2024 11:02 AM - It Cannot Be Edited


Created By: Hanson Leong On 03/28/2024 at 10:37 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: CITY OF SAN RAFAEL - PARKSIDE CHILDREN'S CENTER
FACILITY NUMBER: 213003961

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2024
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...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).
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The director stated that she would have the staff review, sign, and date the meeting notes.
The director also stated that the staff would watch a video about supervising children in a childcare center.
Proof of attendance at the meeting and
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This requirement is not met as evidenced by:
Based on interview and record review, a child was left unsupervised in a classroom, which poses an immediate health, safety, or personal rights risk to children in care.
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watching the video will be required to clear up 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.
SUPERVISOR'S NAME:Daniel J Oquendo
LICENSING EVALUATOR NAME:Hanson Leong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024


LIC809 (FAS) - (06/04)
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