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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005693
Report Date: 04/17/2025
Date Signed: 04/17/2025 01:49:01 PM

Document Has Been Signed on 04/17/2025 01:49 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. SHORT SCHOOLFACILITY NUMBER:
214005693
ADMINISTRATOR/
DIRECTOR:		MICHELLE FOXFACILITY TYPE:
860
ADDRESS:35 MARIN STREETTELEPHONE:
(415) 526-7500
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 40TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/17/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Holly Berends, Sarah Philipsheck, and Jamie RinettiTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On April 17, 2025 at approximately 9:30am, Licensing Program Analysts (LPAs) Catrina Quimbo and Jaclyn Naves, conducted a scheduled, pre-licensing inspection. LPAs met with applicant, Holly Berends, compliance learning trainer, Sarah Philipsheck, and compliance manager, Jamie Rinetti, and explained the purpose of the visit.

Application was submitted to department June 27, 2024. Fire clearance was obtained February 27, 2025 for 40 children. Applicant is requesting 40 preschool children (ages 3 years to 5 years old). The designated site supervisor of program will be Holly Berends.

The facility will operate Monday through Friday, 7:30am to 5:30pm. Preschool program will operate at Short School Elementary School in classroom #1 and classroom #2 only. Community Action Marin (CAM) program has access to classroom #1, classroom #2, utility room (exclusive use), girls restroom (shared with school), boys restroom (shared with school), and entire outdoor area (shared with school). Applicant will submit a rotation schedule of shared spaces to department.

The facility was inspected, indoors and outdoors, for health and safety hazards, and measured to calculate capacity.

Indoors: Preschool program will operate in classroom #1 and classroom #2 only. Total indoor square footage equals 1,582.25 sq. ft. allowing for a capacity of 45 preschool children.

LPAs observed each classroom to be ventilated with appropriate temperature. Each classroom includes a heater and air conditioner, if needed. LPAs observed classrooms to be equipped with furniture, toys and materials that were observed to be age appropriate and in good condition. LPAs observed children's materials to be new, clean and organized. Per applicant, toys and materials will be sanitized weekly or as needed. Flooring in classrooms include carpet and rugs that are clean and in good condition. Per applicant, CAM janitorial services will clean carpets daily. LPAs observed classrooms to have cabinets and drawers with child safety locks installed. LPAs also observed main entrance doors to classrooms with a sound alarm system.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2025
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 5
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)
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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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: C.A.M. SHORT SCHOOL
FACILITY NUMBER: 214005693
VISIT DATE: 04/17/2025
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Storage for children's belongings will be kept in each classroom with children's cubbies. LPAs observed electrical outlets in classrooms to be made inaccessible, with child safety covers. Poisons, cleaning supplies and hazardous materials were observed to be stored behind child safety locked cabinets and/or in classrooms' high shelves. LPAs observed each classroom to include a fully charged fire extinguisher, multiple fully stocked first aid kits, emergency backpacks, smoke alarms and carbon monoxide detectors. LPAs tested carbon monoxide detector in each classroom, which was observed to be working.

Children's medication, will be stored in their assigned classroom, inaccessible to children. Each classroom includes a poster that will maintain children's medications and allergies. There is a refrigerator in each classroom for medication if needed.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) tollfree ADA Information Line at (800) 514-0301 (voice) or (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.

Program plans to provide napping children with floor mats. Sheets and blankets will be provided by CAM program and laundered on site weekly, or as needed. Per applicant, floor mats will be sanitized daily or as needed. LPAs reminded applicant sheets and blankets must be stored appropriately so that they are not touching each other.

Applicant plans for isolation area to be in school lobby, separate from other children. LPAs reminded applicant children must always be supervised when isolated from other children. Program's discipline policy was discussed. CAM's discipline policy includes a positive discipline with an inclusion team.

Each classroom includes a diaper changing table, adult sink and children's sink. Children's restroom will be shared with the school that includes a girls restroom and boys restroom. For children's use, there are 6 sinks and 6 toilets. Total allowable capacity for toilets is 90 children. Total allowable capacity for sinks is 90 children. LPAs observed sink and toilet to be in proper working condition. Applicant stated they are aware children must be supervised going to and from bathroom. LPAs reminded applicant water accessible to children cannot be more than 120 degrees Fahrenheit.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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. SHORT SCHOOL
FACILITY NUMBER: 214005693
VISIT DATE: 04/17/2025
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Program plans to provide a food service that will be morning snack, lunch and afternoon snack. Food will be made prepared by the CAM vendor and brought to the site daily. Staff will prepare and distribute food in each classroom. Reusable utensils and plates will be utilized by children. There is a dishwasher on site that will sanitize children's utensils.

CAM program will provide children with their individual water bottles that can be refilled at center through an accessible water fountain in each classroom. Water bottles will be labeled with children's individual names.

The requirement for Lead Water Testing was discussed (H&S Code 1597.16). Applicant was reminded a facility licensed after July 1, 2022, must have their water fixtures (used for drinking and food preparation) tested for lead 180 days after licensure and every 5 years thereafter. LPA advised applicant to review PIN 21-21-CCP.

Outdoor: Outdoor area includes a side yard, garden/picnic area, small play yard and big play yard. Total outdoor area measures for 23,012.7510 sq. ft. allowing for a capacity of 306 preschool children. Entire outdoor area is fully fenced and enclosed. LPAs did not observe any pools, spas or bodies of water. Side yard and garden/picnic area will be utilized as needed. Small play yard includes a variety of materials that are age appropriate. Big play yard includes a soccer field, black tops and play structure that will be shared with the school. LPAs observed play structure to be labeled for children ages 2 years to 5 years old. There is soft padding under play structure that is in good condition.

LPA reviewed with applicant, the LIC 311A, Records to Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

CAM program plans to communicate with children's families through parent teacher conferences, daily check ins, and electronic communication. Sign in/out sheets will be written and maintained at facility. Applicant stated they are aware emergency disaster drills will be documented when conducted.

Applicant was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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. SHORT SCHOOL
FACILITY NUMBER: 214005693
VISIT DATE: 04/17/2025
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Applicant was informed of the MyChildCarePlan.org site, a consumer education
website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/ subscribe and select the Child Care option to receive email communication.

Based on fire clearance, maximum capacity preschool program can be licensed for is 40 children.

The following corrections are needed prior to the issuance of the license:
-Diaper changing table in each classroom must be within arm's reach to an adult sink.
-Sound alarm system on exit doors to side yard.
-Valve cover in side yard.
-Garbage bins with tight fitting lid in children's restrooms.
-Clarification of toilet tank in boy's restroom.
-Centralized Application Bureau (CAB) final approval of application.

Applicant, Holly Berends, understands that all proof of corrections must be provided to the Department within 30 days, or the application may be denied.

Exit interview conducted and report was reviewed with applicant, Holly Berends.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
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