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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005371
Report Date: 09/19/2025
Date Signed: 09/19/2025 12:40:41 PM

Document Has Been Signed on 09/19/2025 12:40 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:LUCERO, EVELYNFACILITY NUMBER:
214005371
ADMINISTRATOR/
DIRECTOR:		LUCERO, EVELYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 895-8292
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 6DATE:
09/19/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Licensee, Evelyn LuceroTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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On 9/19/2025, at approximately 10:00AM, Licensing Program Analysts (LPAs) Nicole Tran and Jonathan Tse conducted an unannounced, annual inspection. LPAs met with licensee, Evelyn Lucero, and explained the purpose of the visit. Present during LPA’s visit included licensee, 1 assistant, and 6 children (1 infant and 5 preschool age children). Licensee is a large license and is operating within capacity limits and ratio during today’s visit. Hours of operation are Monday to Friday from 7:00AM to 5:00PM.

Licensee lives in a single-level family home with one minor child. All adults living or working in the home have fingerprint clearance on file.

Daycare Areas: Living Room (main play area), Kitchen, Bedroom #1 (not currently in use), Bathroom #1, and Backyard.
Off-limits Areas: Bedroom #2, Bedroom #3, Bathroom #2, and Garage.

With licensee, LPAs inspected the facility for health and safety hazards. LPA observed home to be in good condition and free of debris. Home is equipped with a fully charged fire extinguisher at least the size of 2A10BC, a fully stocked first aid kit, fire alarm, and a smoke and carbon monoxide detector. Poisons, chemicals, and cleaning detergents have been made inaccessible. Off-limit areas are made inaccessible with child safety gates and/or child safety locks.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2025
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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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: LUCERO, EVELYN
FACILITY NUMBER: 214005371
VISIT DATE: 09/19/2025
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LPAs observed electrical outlets to be made inaccessible with child safety covers. Flooring in the home includes rugs that are clean and in good condition. LPAs observed the home to have a variety of toys and equipment that are age-appropriate. There is a fireplace in the living room that is made inaccessible and appropriately barricaded. Cubbies are available for children’s personal storage.

Licensee provides a food service that includes morning snack, lunch, and afternoon snack. Children eat in the living room on age-appropriate furniture. Reusable utensils and plates are utilized for children and are sanitized daily. Filtered drinking water is provided for children in care. Per licensee, no enrolled children have allergies.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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: https://www.ada.gov/resources/child-care-centers/.

Bathroom for children’s use was observed to be in working condition and is equipped with age-appropriate toileting equipment. LPAs observed the cabinet in Bathroom #1 to have a child safety lock installed. There is a diaper changing table in the Living Room. Per licensee, children’s families provide their own diapers and wipes. LPAs observed diapers and children's materials to be appropriately stored. There are multiple garbage bins with tight fitting lids in the home.

Children sleep in cots and pack and play cribs depending on their age and needs. Per licensee, families provide all bedding materials and the licensee washes them weekly. LPAs observed sheets and blankets to be appropriately stored when not in use. Licensee maintains sleeping logs for napping infants. LPAs observed sleeping logs to include the 15 minute time stamp of when the infant is checked on while napping and the initials of the staff member checking on the infant. LPAs observed a pack and play crib to be free of loose articles and had an appropriate sized mattress with a tight fitting sheet.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: LUCERO, EVELYN
FACILITY NUMBER: 214005371
VISIT DATE: 09/19/2025
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LPAs discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPAs also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Backyard is fully enclosed and fenced. The outdoor area has baby gates sectioning off different zones for play. There are a variety of outdoor toys and materials that are age-appropriate. There is sufficient shade in the outdoor area and tanbark underneath the swings to provide cushioning. LPAs observed a hot tub on the right side of the backyard. The hot tub has a cover but the latches on one side need to be repaired. Per licensee, children do not play on that side of the backyard. LPAs advised licensee to repair the cover or make the area inaccessible to children in care.

Licensing documentation is properly posted and made available for review. A childcare roster was also made available for LPAs’ review. Emergency disaster drills are conducted and are appropriately documented. The last disaster drill was conducted on 8/16/2025. Licensee's and their assistant’s Mandated Reporter certifications will expire on 8/2026. Licensee's and their assistant’s EMSA certified pediatric CPR/First Aid training will expire on 3/2026. Licensee has required immunizations on file. Per licensee, there are no weapons or firearms in the home.

LPAs reviewed facility records that included all enrolled children's records, licensee's record and assistant's records. During review, LPAs observed that the assistant's immunization records had not been updated. Children's records are complete.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: LUCERO, EVELYN
FACILITY NUMBER: 214005371
VISIT DATE: 09/19/2025
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at
www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

Licensee was informed of the MyChildCarePlan.org website; 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.

During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

No deficiencies were issued today during LPA's visit on 9/19/2025.

See LIC 9102-TV for a technical violation given today regarding staff records.

A notice of site visit was given and must remain posted for 30 days. Appeal rights were provided to licensee.

Exit interview conducted and report was reviewed with the licensee, Evelyn Lucero.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC809 (FAS) - (06/04)
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