214200085-7-23-2025-05-CC-JNAS-DJUUPF-20250723154527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214200085
Report Date: 07/23/2025
Date Signed: 07/23/2025 03:45:42 PM

Document Has Been Signed on 07/23/2025 03:45 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:	GONZALEZ ORTEGA, DEVORA		FACILITY NUMBER:	214200085
ADMINISTRATOR/ DIRECTOR:	GONZALEZ ORTEGA, DEVORA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 455-8138
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 7	DATE:	07/23/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:07 PM
MET WITH:	Devora Gonzalez Ortega		TIME VISIT/ INSPECTION COMPLETED:	04:05 PM

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 7/23/2025, Licensing Program Analyst (LPA) Naves conducted an unannounced annual visit to the Family Childcare Home (FCCH) listed above. LPA met with the Licensee, Devora Gonzalez Ortega, and explained the purpose of the visit. 7 children (2 infants, 5 pre-k,), the licensee, and the licensee’s 2 daughters (12 and 17 year olds) were present during the visit. The licensee holds a large license and is within capacity limits and ratios on this day. The licensee rents the 2 bedroom 2 bathroom home and lives with her husband and daughters (both under the age of 18). The hours of operation are Monday through Friday from 7:00 a.m. to 5:30 p.m. LPA was informed a dog lives in the home, and according to the licensee, the dog is fully vaccinated. LPA observed that all required documents, such as the facility license, the Notification of Parental Rights, and the Earthquake Preparedness Checklist, were displayed in a prominent, publicly accessible location. The most recent emergency disaster drill was conducted on 2/3/2025, and the LPA observed that it was properly documented. LPA reviewed the emergency disaster drill log and found that they were conducted every six months. Licensee rents this single family single story home which is 2 bedrooms 2 baths cont pg 2 >>>>

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025

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: GONZALEZ ORTEGA, DEVORA	FACILITY NUMBER: 214200085
	VISIT DATE: 07/23/2025

NARRATIVE

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Day-care Areas: Living Room, Bathroom #2, Backyard and Deck
Off-limits Areas: Kitchen, Bedrooms #1 and # 2, Bathroom #1, and Front Yard. The licensee understands that off-limits areas may not be used for childcare during business hours.

LPA conducted inspections of the indoor and outdoor daycare areas to identify health and safety hazards. LPA found the home's interior to be clean and orderly, with proper heating and ventilation for safety and comfort.

Disinfectants, cleaning solutions, poisons, and other items that could pose a danger were stored in the licensee’s room and were inaccessible to the children. The bathroom was found to be clean and fully operational. The toilet and handwashing facility were well-kept, safe, and clean. A diaper changing station is available for children to use.

LPA observed that the daycare areas had age-appropriate toys, furniture, and educational materials. No equipment, such as walkers, bouncers, or similar objects, was present in the home. The fireplace was observed to be properly barricaded. The home was observed to have individual permanent or portable storage space for the children’s clothing and personal belongings. Electrical outlets were observed to be properly covered with child safety. According to the licensee, no firearms or weapons are on the premises.

The outdoor playground was enclosed by a fence, and the outdoor play equipment was safe for the children to use. The areas around and under high climbing equipment, swings, slides, and similar equipment were cushioned with material that absorbs falls. No bodies of water, such as pools or spas, were present on site.

According to the licensee, the children bring their own food. LPA reminded the licensee about the importance of labeling the child’s container with the child’s name and properly storing or refrigerating it. Snacks were observed to be available for the children.
cont pg 3 >>>>

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025

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: GONZALEZ ORTEGA, DEVORA	FACILITY NUMBER: 214200085
	VISIT DATE: 07/23/2025

NARRATIVE

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page 3
The sleeping/resting area was observed to be clean and sanitary. Playpens, cots, cribs, sleeping mats, blankets, and sheets are available for children to use. LPA also observed that the infant mattresses were firm and appropriately covered with a fitted sheet appropriate to the size of the mattress. LPA reminded licensee that cribs and play yards must be free of all loose articles and objects for all children under 24 months.

LPA reviewed five children’s files and confirmed that all five children have complete files that include their emergency contact and medical information and sleep logs for children under two years old. LPA reminded the licensee to maintain a sleeping log, documenting the child’s sleep every 15 minutes for children under two years old. LPA and licensee reviewed all required forms to be in children’s files.

LPA reviewed the licensee’s files and confirmed that all required forms were present. LPA found that the licensee possesses a current Pediatric First Aid/CPR certification expiring on 3/2027. LPA reminded licensee of Mandated Reporter training needing to be renewed by 2/2026 and it must be under her own name not facility name. Licensee understood all things reviewed and discussed today.

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.

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/.
cont pg 4 >>>>

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025

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: GONZALEZ ORTEGA, DEVORA	FACILITY NUMBER: 214200085
	VISIT DATE: 07/23/2025

NARRATIVE

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LPA 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. LPA 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.

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.

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.

No deficiencies were issued today during LPA's visit.

A copy of today's report was given to the Licensee, Devora Gonzalez Ortega.

A Notice of Site Visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Devora Gonzalez Ortega.

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025

LIC809 (FAS) - (06/04)

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