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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005550
Report Date: 08/13/2021
Date Signed: 08/17/2021 05:05:13 PM

Document Has Been Signed on 08/17/2021 05:05 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 (PS)FACILITY NUMBER:
214005550
ADMINISTRATOR:LOMBARDI, KELSEYFACILITY TYPE:
850
ADDRESS:1123 COURT STREETTELEPHONE:
(415) 526-7500
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 68TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kelsey LombardiTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Haydee Caliboso met with Kelsey Lombardi (Alignment Manager) and Paula Cifuentes for a pre-licensing inspection on 8/13/21. The applicant has requested a combination of preschool program and infant with toddler component program. The preschool program will be part of a combination center as the applicant has also applied for an infant program with toddler component license for 28 children (ages birth to 36 months) at the same location. The applicant has requested 48 preschool children ages 2 to Kindergarten. 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 preschool program will be Paula Cifuentes. The facility was inspected today, indoor and outdoor, for health and safety hazards and measured to calculate capacity. This inspection included a technical assistance inspection for COVID-19 guidance and support.

Indoor: There are 2 classrooms that will be used for the program and the following square footage was calculated for each room: Room (#1) 552.09 sq. ft, allowing for a capacity of 16 children. Room (#2) 612.811 sq. ft, allowing for a capacity of 17 children. The total indoor classroom measures 1,164.901 sq. ft allowing for a capacity of 33 children. The classrooms 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 to be utilized for napping children. Parents will provide a sheet and blanket for their child. Bedding is sent home to be washed weekly or as needed. Mats will be cleaned daily or as needed. The classroom is equipped with a fire extinguisher, smoke, and carbon monoxide detectors.
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)
Page: 1 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 (PS)
FACILITY NUMBER: 214005550
VISIT DATE: 08/13/2021
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The classroom has a kitchen area with a working refrigerator where snack food is stored. Each classroom has garbage cans with tight-fitting lids. The classrooms have a designated backpack with a first aid kit and emergency supplies. 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 program will provide lunch, morning and afternoon snacks daily. Only disposable products will be used for food service.

Each of the classrooms have 2 sinks and 2 toilets available for children to use. The capacity for 4 toilets is 60, and the capacity for 4 sinks is 60. There is additional 2 sinks inside the Room#1 available for children to use. The bathroom is clean and does not have any health or safety hazards. All cleaning supplies and hazardous items are stored in a locked cabinet made inaccessible to children. Isolation area for ill children located inside the Site Supervisor’s office, and staff bathrooms will be used for ill children. There are designated bathrooms for staff to use. The program will provide water for indoor and outdoor use. In addition, pitchers of water and disposable cups will be provided for indoor and outdoor use.

Outdoor: The playground was calculated for 2, 450 sq. ft, allowing for a capacity 70 children. The outdoor area is enclosed by a fence at least 4 ft. tall, and was observed to be safe, and equipped with toys that are age-appropriate for children. There is a sandbox in each playground. Sandboxes will be inspected daily and kept free of hazardous materials. There is natural shade and commercial fabric shade structure for children. The playground has climbing structures and slides. Woodchips are used under the climbing structure for cushion. There are age-appropriate toys in good condition in the playground made accessible for children to use. Sheds for storage will remain closed and locked when children are present. LPA reminded the Paula Cifuentes to ensure ratio and supervision are observed at all times. The facility will conduct and log fire drills once every six months, and the log will be available upon request.
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)
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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 (PS)
FACILITY NUMBER: 214005550
VISIT DATE: 08/13/2021
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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, Food Service, Transportation-none provided, Parents Rights, and Reporting Requirements. 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 Paula Cifuente. 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 33 children. The following is required prior to licensure:

· Updated LIC 200A
· Updated LIC 999. Indicating classrooms used for day care setting for children enrolled in the program.
· Additional safety measures or barriers in placed on the porch on the 2nd floor classrooms.

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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