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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410503938
Report Date: 04/02/2025
Date Signed: 04/02/2025 12:48:34 PM

Document Has Been Signed on 04/02/2025 12:48 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:VAZQUEZ, ROSA R.FACILITY NUMBER:
410503938
ADMINISTRATOR/
DIRECTOR:		VAZQUEZ, ROSA R.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 365-3128
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 7DATE:
04/02/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:29 AM
MET WITH:Rosa VazquezTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 04/02/25 at approximately 9am Licensing Program Analyst (LPA) Katie Krenn conducted an unannounced annual inspection. Rosa Vazquez and explained the purpose of today’s visit. Present in the facility are licensee and an assistant caring for seven children (4 infants and 3 preschool age). All adults living and working in the home have a criminal record clearance on file.

Licensee owns home, which is a 2 bedroom, 1 bathroom, single level house. Licensee lives with one adult and a minor child.
Hours of operation: Monday - Friday from 8am - 5pm.
Daycare areas: Playroom/Garage, Living Room, Side yard/Driveway, and Side yard with lawn.
OFF limit area: Kitchen (pass by only), Bedrooms #1 and #2, Bathroom #1 (all children are currently in diapers), and Backyard. All off limit areas are properly barricaded.
LPA confirmed the email and phone numbers on file are current.

LPA observed home to be clean and in good repair with proper temperature and ventilation. There were a variety of age-appropriate toys and equipment in the home which were in good condition. Home does not have a fireplace. There are no pets in the home. There were no pools, spas or bodies of water on the property. All cleaning supplies, poisons and other chemicals were stored inaccessible to children. Isolation in the living room.

LPA observed that required documents, such as the facility license and the Notification of Parental Rights, were displayed and visible to the public. LPA gave licensee a copy of the Earthquake Preparedness Checklist, for posting.

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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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Document Has Been Signed on 04/02/2025 12:48 PM - It Cannot Be Edited


Created By: Katie Krenn On 04/02/2025 at 11:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VAZQUEZ, ROSA R.
FACILITY NUMBER: 410503938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2025
Plan of Correction
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Licensee and assistant will complete the mandated report training the child care portion.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Daniel J Oquendo
NAME OF LICENSING PROGRAM MANAGER:
Katie Krenn
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


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: VAZQUEZ, ROSA R.
FACILITY NUMBER: 410503938
VISIT DATE: 04/02/2025
NARRATIVE
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The most recent emergency disaster drill was conducted on 2/3/2025, and the LPA observed that it was documented. LPA reviewed the emergency disaster drill log and found they were conducted at least once every six months.

LPA inspected the indoor and outdoor daycare areas to identify health and safety hazards. LPA observed that the home had a fire extinguisher, a first aid kit, and one multiple carbon monoxide and three smoke detectors. LPA did not test the smoke and carbon monoxide detector because the children were napping.



The facility offers different options for children to rest or nap, including folding mats and pack-n-plays. LPA observed that sheets and blankets were available for the children. Infant mattresses are firm and equipped with appropriately sized sheets. All cribs are well-maintained and free of loose items that could pose safety risks.

LPA reviewed the files of seven children and confirmed that all necessary forms were present and completed for each child. LPA also reviewed the 15-minute sleep records for the four children under two and confirmed they were documented. LPA reminded the licensee to maintain form LIC 9227 for children under one in their files. LPA printed copies of the LIC 9227 for two infants during the visit.

LPA reviewed the licensee’s files and confirmed that all necessary forms were present and completed. LPA confirmed that the licensee holds a valid Pediatric First Aid/CPR certification, which is set to expire in March 2027. LPA did not see LIC 9108 Statement Acknowledging the requirement to report child abuse. LPA printed copies and the licensee and assistant signed them during the visit.

LPA reviewed the Mandated Reporter Training requirement of the two hour Child care training. Licensee will send copies once the training is completed.

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
Page: 5 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: VAZQUEZ, ROSA R.
FACILITY NUMBER: 410503938
VISIT DATE: 04/02/2025
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To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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 [or facility representative] 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.

LPA discussed the safe sleep regulations with licensee [or facility representative] and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] 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.

LPA issued one type B citation.

Appeal Rights were given to the licensee and LPA reviewed them.

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 Rosa Vazquez.
NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
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