214005685-6-5-2025-05-CC-BVAN-DHCNX7-20250605105040

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214005685
Report Date: 06/05/2025
Date Signed: 06/05/2025 10:50:59 AM

Document Has Been Signed on 06/05/2025 10:50 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	RODRIGUES, ADRIANY		FACILITY NUMBER:	214005685
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 4	CENSUS: 4	DATE:	06/05/2025
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Adriany Rodrigues		TIME VISIT/ INSPECTION COMPLETED:	11:10 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On June 5, 2025., Licensing Program Analyst (LPA) Van conducted an unannounced inspection to review the licensee's request to increase her license capacity to a large license. LPA met with the licensee, Adriany Rodrigues. At the time of inspection, the licensee and her husband supervised four infants. The Licensee complies with the Licensee's capacity and limitations. The licensee submitted a request for a capacity increase on May 16, 2025. However, at the time of application submission, the licensee had not yet completed the one-year experience requirement necessary to be eligible for a large license increase. Her one-year anniversary for this experience is on May 28, 2025. During the inspection, the Licensee’s adult son provided Portuguese translation. Days and operations hours are 7:30 AM – 5:00 PM. LPA inspected the facility for any health and safety hazards. Currently, the childcare areas include the living room, the bathroom, bedroom #1, and the outside yard (concrete area only). Off-limits areas include the kitchen, bedroom #2, the master bedroom (Inside the bathroom), the gravel area, and the outside yard beyond. However, as part of the capacity increase, the Licensee has requested to include two previously off-limit areas as childcare spaces: the family room (living room #2) and bedroom #2. Continued on page 2.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: RODRIGUES, ADRIANY	FACILITY NUMBER: 214005685
	VISIT DATE: 06/05/2025

NARRATIVE

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page 2.
The new childcare areas now consist of a living room, a bathroom, bedroom #1, bedroom #2, a family room (also referred to as living room #2), and an outside yard (limited to the concrete area). The new Off-limit areas are the kitchen, master bedroom (Inside bathroom), gravel area, and beyond in the outside yard.

The childcare areas are clean and equipped with age-appropriate toys and learning materials. There is sturdy, age-appropriate furniture that is in good condition. The facility floors are well-maintained and free of any hazards. The children's bathrooms are in good working order and properly sanitized. All materials and surfaces accessible to the children are clean and free of toxins. The facility is equipped with a smoke detector, a carbon monoxide detector, fully charged fire extinguishers, and a working telephone. All cleaning solutions, poisons, and other hazardous chemicals are stored safely out of children's reach.

LPA reminded the licensee that equipment such as baby bouncers and walkers is not allowed at the childcare during operating hours.

The licensee has indicated that the Fire Marshal inspected the premises a few days ago. However, the licensee must address several minor improvements and repairs. The Fire Marshal will conduct a follow-up inspection before granting the necessary fire clearance.

During the inspection, the following was discussed and reviewed with the Licensee:
· Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
Continued on page 3.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: RODRIGUES, ADRIANY	FACILITY NUMBER: 214005685
	VISIT DATE: 06/05/2025

NARRATIVE

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page 3.
· Incidentals Medical Services (IMS) policy was discussed. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm
· The Licensee was given information regarding PIN 20-24-CCP Safe Sleep Regulation
· The Licensee was reminded that as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.622.
· The Licensee was reminded about Mandated Reporter training available on the CCLD website. All staff hired must complete training every two years. Training can be taken online at www.mandatedreporterca.com. If training is unavailable in the native language, a statement can be written stating exemption until the translation is available.
· The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website.
· Mandatory Posting Requirements: License, Emergency Disaster Plan, and Notification of Parents' Rights Poster.
· The capacity limit of a large license was discussed with the Licensee. The Licensee was reminded that a Helper must be present when operating at a large capacity. Additionally, Pediatric First Aid and CPR are required for all helpers.

Continued on page 4.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: RODRIGUES, ADRIANY	FACILITY NUMBER: 214005685
	VISIT DATE: 06/05/2025

NARRATIVE

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page 4.
Before a recommendation for an increase in the capacity of a large family childcare home, the licensee must satisfy the following:

- Fire clearance STD 850 form from the fire department.
- All floor heater vents in the family room and bedroom #2 must have proper screens.
- All sharp corners and edges must have soft corner cushions installed, including the coffee table in the family room and the bed’s legs in bedroom #2.
- Ensure all electrical wires are properly covered
- The storage double folding doors must have child-proof locks or latches installed.
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A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted, and the report was reviewed with the licensee, Adriany Rodrigues.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC809 (FAS) - (06/04)

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