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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410517836
Report Date: 12/17/2025
Date Signed: 12/17/2025 04:39:16 PM

Document Has Been Signed on 12/17/2025 04:39 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:SAN CARLOS-BELMONT AFTER SCHOOL-CENTRAL SITEFACILITY NUMBER:
410517836
ADMINISTRATOR/
DIRECTOR:		TEDFORD,TERRI&MEADE,DIANEFACILITY TYPE:
840
ADDRESS:525 MIDDLE ROADTELEPHONE:
(650) 593-4229
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 105TOTAL ENROLLED CHILDREN: 105CENSUS: DATE:
12/17/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Katrina San - FelipeTIME VISIT/
INSPECTION COMPLETED:
04:58 PM
NARRATIVE
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On 12/17/2025, Licensing Program Analysts (LPA) J. Badger arrived at the above-named facility to conduct an unannounced annual inspection. The LPA met with Katrina San Felipe, the facility’s site director. The purpose of today’s visit was explained, and the LPA was granted entry to inspect the facility.

The program operates in classrooms 13, 14, 17 and the library. Present at the facility were 77 school aged children with eight teachers, including the director. The facility was in compliance with staff-children ratio today.

The days and hours of operation: Monday - Friday from 7:30 a.m. to 6 p.m.

All staff members present during the inspection had their criminal record clearances verified through the CDSS Guardian Background Check site and were found to have eligible clearance status.

LPA toured and inspected the physical plant with the site director to identify potential health and safety hazards. The facility is well maintained and has proper heating, lighting, and ventilation. The center is currently signing-in and signing-out using paper form, located on a clip board near the entrance of class room 14. Each classroom was well stocked with age-appropriate toys and educational materials. The furniture is sturdy and well maintained. The facility has carbon monoxide, centralized smoke detectors, and functioning telephones located in each room. All hazardous materials, including cleaning solutions and poisons, are kept out of the reach of children.

There is a fully charged fire extinguisher located in each of the classrooms. All toilets and hand washing sinks are in good working order and have proper sanitation. There is a separate bathroom available for staff use on the premises. .

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2025
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 5
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: SAN CARLOS-BELMONT AFTER SCHOOL-CENTRAL SITE
FACILITY NUMBER: 410517836
VISIT DATE: 12/17/2025
NARRATIVE
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LPA inspected the outdoor play area for health and safety hazards. The outdoor play area was clean, and the ground was free of debris, there were age-appropriate toys that were in good condition. The play structure was sturdy and there was padding underneath to cushion a fall. According to the director, no pools, spas, or bodies of water are on the premises. Furthermore, the licensee stated that the center has no guns or weapons on site. All storage containers for solid waste/trash within the center have proper tight-fitting lids.

The site director said that the center offers morning snacks and afternoon snacks. Children bring their own water bottles from home and water is refilled by the water stations on the yard or filled from pitchers of water located in the classroom. Children keep their belongings in cubbies.

All the required postings were observed to be visible to the public, including the facility License, Notification of Parent Rights, Personal Rights, Car Seat Law, Emergency Disaster Plan, and a record of Daily activities.

LPA selected 6 random children's records, and 4 personnel records that were reviewed during the inspection. Records review showed the facility has complete records of each child, including, admission agreements, emergency contact, and personal rights. Multiple staff members have records of valid CPR certifications and mandated reporter training certificates. The educational qualifications of the director and staff showed they possessed the required ECE units.

The site director stated that the center conducted the last emergency drill on 11/10/2025. The director was reminded that emergency drills are to be conducted at least every 6 months.

The director was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC809 (FAS) - (06/04)
Page: 3 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAN CARLOS-BELMONT AFTER SCHOOL-CENTRAL SITE
FACILITY NUMBER: 410517836
VISIT DATE: 12/17/2025
NARRATIVE
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record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. 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.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

LPA verified that the lead testing was completed in accordance with the Written Directives outlined in PIN 21-21.1-CCP.

LPA referred site director, Katrina San - Felipe, to the Department website for Lead Toxicity Prevention and Water Testing Information.

CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

LPA discussed Child Abuse Mandated Training AB1207 with the Director. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

Pesticide regulations were discussed with the Site Director. In accordance with the Healthy Schools Act, California law requires that anyone using any pesticide must be trained every year in integrated pest management and the safe use of pesticides around children. The director was advised that a free one-hour online course is available on the Department of Pesticide Regulation's website: www.cdpr.ca.gov/schoolipm/training. For questions, email ccipmlist@cdpr.ca.gov.

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAN CARLOS-BELMONT AFTER SCHOOL-CENTRAL SITE
FACILITY NUMBER: 410517836
VISIT DATE: 12/17/2025
NARRATIVE
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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. .

A notice of site visit was given and must remain posted for 30 days.

An exit interview conducted, and a report was reviewed with the facility representative, Katrina San - Felipe.

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC809 (FAS) - (06/04)
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