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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005538
Report Date: 03/04/2021
Date Signed: 03/23/2021 09:58:35 AM

Document Has Been Signed on 03/23/2021 09:58 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:C.A.M. (CFS) MANZANITAFACILITY NUMBER:
214005538
ADMINISTRATOR:LIEBHARD, MONIQUEFACILITY TYPE:
850
ADDRESS:630 DRAKE AVENUE, PORTABLE CTELEPHONE:
(415) 526-7500
CITY:SAUSALITOSTATE: CAZIP CODE:
94965
CAPACITY: 20TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
03/04/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Paula Fuentes & Sanaa MehtarTIME COMPLETED:
01:48 PM
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Licensing Program Analyst (LPA) Haydee Caliboso met with Paula Fuentes and Sanaa Mehtar today for a pre-licensing inspection. During today’s inspection, COVID-19 technical assistance, guidance, and support were provided. The applicant has requested a capacity of 20 children ages 2 to 6 years old. The facility building that will be used for the program is at Portable C building. The facility will operate Monday - Friday; 7:30 AM to 6:00 PM. The facility was inspected today, indoor and outdoor, for health and safety hazards and measured to calculate capacity.

Indoor: There is one portable classroom that will be used for the program and the following square footage was 1,165 sq. ft. allowing for a capacity of 20 children. The classroom and furniture equipment are clean and in good condition. Children’s toys and supplies are orderly, in good condition, and age-appropriate. There is storage space for children's personal belongings and mats will be used for napping children. Mats will be cleaned daily or as needed. The program will provide a sheet and blanket for each child. Bedding is washed weekly or as needed. The facility is equipped with a fire extinguisher and smoke and carbon monoxide detectors. The classroom has a kitchen area with a working refrigerator where snack food is stored. The garbage cans have tight-fitting lids. The classroom has a designated first aid kit and emergency supplies. Refrigerated medications will be stored separately from food.
Cont. 809 pg. 2
SUPERVISORS NAME: Alma Malig
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: C.A.M. (CFS) MANZANITA
FACILITY NUMBER: 214005538
VISIT DATE: 03/04/2021
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Medication will be administered with parental consent and will be kept in the child’s file for record. All medication will be logged when administered to children. The program will provide breakfast, lunch, and snacks daily. Only disposable products will be used for food service. Also, pitchers of water and disposable cups will be provided for indoor and outdoor use.

The portable classroom has a total of 2 sinks and 2 toilets available for children to use. All cleaning supplies and hazardous items are stored in a locked cabinet made inaccessible to children. The isolation area for ill preschool children is located in the corner of the office/teacher space. Staff bathrooms will be used for ill children until parents arrive for pick-up.

Outdoor: The facility does not have a designated outdoor play area. The program has submitted an open space playground waiver permit to Marin City Community Services District (MCCSD) to use the children’s playground at Rocky Graham Park located at 850 Drake Ave, Sausalito which is 0.2 miles away from the facility. The program has obtained the approval of a permit from MCCSD for playground usage until June 30, 2021. The program will ensure permit for park usage is current and up to date. The park was inspected and meets the requirements for the open space waiver. Children will walk to the park. Teachers will bring children’s water bottles for playground use. LPA reminded Paula Fuentes and Sanaa Mehtar to ensure ratio and supervision are observed at all times and gates are locked. The facility will conduct and log fire drills once every six months, and the log will be available upon request.

The following items were reviewed as part of today’s visit: Recordkeeping for staff, children, and facility records, care and supervision of the children, child discipline procedures – staff will use positive discipline.
Cont. 809-C pg. 3
SUPERVISORS NAME: Alma Malig
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: C.A.M. (CFS) MANZANITA
FACILITY NUMBER: 214005538
VISIT DATE: 03/04/2021
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Emergency Evacuation Procedures, Medication Policies, Isolation of Sick Children, Napping Requirements, Food Service, Transportation-none provided, Parents Rights, and Reporting Requirements.

This facility will provide Incidental Medical Services – IMS. LPA reviewed the storage area for medication and equipment/supplies and reviewed forms that will be used. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at http://www.ada.gov/childqanda.htm

LPA reviewed the COVID-19 self-assessment guide and required postings were posted in the classrooms. An electronic copy of this 3-page report was emailed to Paula Fuentes, Sanaa Mehtar, and Kelsey Lombardi. Applicants were asked to review the report and return a signed copy of the report to LPA Haydee Caliboso.

Based on available square footage, sinks, and toilets, LPA Haydee Caliboso will recommend licensure of this facility for a maximum capacity of 20 children.

The following supportive document need to be made and submitted for further review:
  • Updated Admission Agreement

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
LIC809 (FAS) - (06/04)
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