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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005549
Report Date: 08/13/2021
Date Signed: 08/17/2021 05:04:32 PM

Document Has Been Signed on 08/17/2021 05:04 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:C.A.M. (CFS) DE COLORES (INF)FACILITY NUMBER:
214005549
ADMINISTRATOR:LOMBARDI, KELSEYFACILITY TYPE:
830
ADDRESS:1123 COURT STREETTELEPHONE:
(415) 526-7500
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 25TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kelsey Lombardi & Carol LangTIME COMPLETED:
11:30 PM
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Licensing Program Analyst (LPA) Haydee Caliboso met with applicant Kelsey Lombardi (Alignment Project Manager) and Carol Lang on 8/13/21 for a pre-licensing inspection. The applicant has requested a combination of an infant with toddler component program. The infant/toddler program will be part of a combination center as the applicant has also applied for a preschool license for 48 children (ages 2 to entry into first grade) at the same location. The applicant has requested for 9 infants, ages birth to 18 months, and 16 toddlers, ages 18 months to 36 months. The facility is located on St. Paul Episcopal Church and plans to operate Monday - Friday; 7:300 AM to 6:00 PM. The designated Site Supervisor for the infant/toddler program will be Carol Lang. The facility was inspected today, indoor and outdoor, for health and safety hazards, and was measured to calculate capacity. This inspection included a technical assistance inspection for COVID-19 guidance and support.

Indoor: There are two classrooms that will be used for the program. There is a designated classroom for the infant program and for the toddler program. The infant classroom was calculated for 451 sq. ft., allowing for a capacity of 12 infants. Toddler classroom was calculated to be 737.62 sq. ft., allowing for a capacity of 16 toddlers. The classrooms are observed today to be clean and equipped with a fire extinguisher, and both smoke and carbon monoxide detectors. The facility is adequately ventilated and free of insects and bugs. 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. The facility has a kitchen with a built-in counter-top area, sinks available for staff and children to use, and garbage cans with tight-fitting lids. The facility has a first aid kit in each classroom and a designated backpack with emergency supplies.
Cont. 809 pg 2.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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) DE COLORES (INF)
FACILITY NUMBER: 214005549
VISIT DATE: 08/13/2021
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Refrigerated medications will be stored separately from food. 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 facility has a designated kitchen area where food is prepared, a working refrigerator, and a working dishwasher where utensils are to be cleaned. The program will provide morning and afternoon snacks, and lunch daily. The program will provide a sheet and blanket for the children. Bedding is to be washed twice per week or as needed. Cots will be used for older infants and will be cleaned daily or as needed. The toddler classroom has 3 toilets and 3 sinks available for children to use, and a diaper changing table within arm’s reach of a sink. The bathrooms were observed to be clean and with no health or safety hazards.

Infant: There is storage for infants’ personal belongings. The program will provide diapers and wipes for the infant. The program will also provide bottles/nipples and any other food service items for each infant, and the staff will ensure breastmilk and or milk formula is served fresh daily to the infant. The infant classroom has a built-in counter-top area, with a sink which includes bottle warmers and a refrigerator. The bottle warmer is out of reach of the children.

There are 3 cribs available for infant to use. Applicant has stated, additional cribs will be purchased as enrollment increases. Drinking water for the children will be provided by plastic baby water bottles or cups with lids provided by the program. Medications for infants will be stored in the classroom in high cabinets or in locked boxes in the refrigerator. All furnishings and equipment are observed to be safe, in good condition, and age appropriate. The diaper changing table area has a sink within arm’s reach. Staff will meet and review the individual written needs and service plans quarterly with the parents. Plans will be kept in the children’s files. There is a separate bathroom available for staff to use. The isolation area for ill children is located at the site supervisor’s office. Staff bathrooms will be used for ill children, if needed, until parents arrive for pick-up.
Cont. 809 pg.3
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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) DE COLORES (INF)
FACILITY NUMBER: 214005549
VISIT DATE: 08/13/2021
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Children in the program will be signed in and out daily by parents using an electronic signature. The facility will conduct and log fire drills once every six months, and the log will be available upon request. All cleaning supplies and hazardous items are stored in a locked cabinet made inaccessible to children.

Outdoor: The outdoor area measures a total of 627 sq. ft., allowing for a total of 8 children. The program will submit a request waiver for the infant and toddler program scheduled outdoor rotation usage. The facility’s outdoor playground is enclosed and gated with a fence approximately 4 ft. tall. The outdoor space was observed to be clean, safe, and equipped with toys that are age-appropriate for children. The outdoor space playground has pea gravel for cushion.

The following items were reviewed as part of today’s visit: Record keeping for staff, children, and facility records, care and supervision of the children, child discipline procedures – staff will use positive discipline and redirection. Emergency Evacuation Procedures, Medication Policies, Isolation of Sick Children, Napping Requirements, Safe Sleep and Individual Infant Sleeping Plan (LIC 9227), Food Service, Transportation-none provided, Parents Rights, and Reporting Requirements were reviewed today. This facility will provide Incidental Medical Services – IMS. LPA reviewed 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 publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

An electronic copy of this three-page report was emailed to Kelsey Lombardi and Carol Lang. Applicant was asked to review the report and return a signed copy of the report to LPA Haydee Caliboso. COVID-19 Self-assessment guide was received and reviewed today with the Site Supervisor Carol Lang.

Based on available square footage, sinks, and toilets, LPA Haydee Caliboso will recommend licensure of this facility for a capacity of 28 children. However, as of today the applicant has applied for a capacity of 24 children only. The following is required prior to licensure:

· COVID-19 Self-Assessment Guide
· Letter of waiver for scheduled outdoor rotation
  • Updated LIC 200A
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
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