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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004621
Report Date: 08/28/2025
Date Signed: 08/28/2025 03:11:18 PM

Document Has Been Signed on 08/28/2025 03:11 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:ZULHENDRI, FELICIA AND SIMAN, SUDHARMONOFACILITY NUMBER:
384004621
ADMINISTRATOR/
DIRECTOR:		ZULHENDRI, FELICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 638-9071
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94107
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
08/28/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Felicia Zulhendri and Sudharmono SimanTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On August 28th, 2025, at approximately 1:15 PM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced, annual inspection. LPA met with licensees, Felicia Zulhendri and Sudharmono Siman, and explained the purpose of the inspection. Present during LPA’s visit included both licensees, and 11 enrolled children (11 preschoolers). The licensee is a large license and is operating within capacity limits and ratio.

Licensees rent the apartment unit, which is 2 bedrooms, 2-bathroom, single level unit on the 1st level of apartment complex. Licensees live in home with there minor child. All adults living and working in the home have fingerprint clearance. Facility operates Monday Through Thursdays 8:30 AM to 4:45 PM, and Fridays from 9:00 AM to 4:00 PM.

Day Care Areas: First Floor Unit: Living Room, Dining Room, Bedroom 2, Bathroom 2, and Back Patio

Off Limit Areas: Bedroom 1, Bathroom 1, and Storage rooms.

At approximately 1:30 PM, LPA toured day care areas of home with licensee. LPA observed the home to be in repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in working condition. LPA observed a fully stocked accessible first aid kit backpack located in the closet area near children's bathroom. Licensees also have additional First Aide supply in kitchen area. LPA did not observe any accessible cleaning supplies, poisons, and solutions in day care areas. LPA observed electrical outlets to be made inaccessible with child safety outlet covers. Home is equipped with a fully charged fire extinguisher and multiple smoke and carbon monoxide detectors. LPA did not test the detector due to being located on high ceilings of the unit. Per licensees, they are working. Licensee does not have any children in care with allergies or IMS plans. Per licensees, they do not provide food for the children in care. Parents or authorized representatives provide lunch.

At approximately 2:00 PM, LPA observed the bathroom for children's use was in proper working condition. LPA observed the bathroom to include appropriate toileting equipment and sanitation products. LPA did not observe any hazardous materials to be accessible to children in the bathroom.

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NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Janet Gil
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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 4
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: ZULHENDRI, FELICIA AND SIMAN, SUDHARMONO
FACILITY NUMBER: 384004621
VISIT DATE: 08/28/2025
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LPA did not observe any pools, spas, or bodies of water in day care areas. LPA observed outdoor patio for children's use was fully enclosed and included 4 benches.

LPA reviewed 6 children records which were complete. The children’s files have a record of emergency identification information and required immunization. LPA reviewed staff records for both licensees, which were complete. Licensee's CPR/First Aid certificates are current and will expire 1/2026. The licensee’s Mandated Reporter training certification are both also current. The licensees also have required immunization available for review.

Licensee has licensing documentation properly posted and available for review. The licensees also maintain a childcare roster that was made available for review. Emergency disaster drills are conducted at least once every six months. The last disaster drill was conducted on June 17th, 2025. Per licensees, there are no weapons or firearms in the home.


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.

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NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Janet Gil
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ZULHENDRI, FELICIA AND SIMAN, SUDHARMONO
FACILITY NUMBER: 384004621
VISIT DATE: 08/28/2025
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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.

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/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

On this date, 8/22/2025, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

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

No deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Sudharmono Siman.
NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Janet Gil
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
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