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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410518747
Report Date: 04/15/2025
Date Signed: 04/15/2025 03:52:42 PM

Document Has Been Signed on 04/15/2025 03:52 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:RCSD CHILD DEV SERVICES-HOOVER STATE PRESCHOOLFACILITY NUMBER:
410518747
ADMINISTRATOR/
DIRECTOR:		PENA, ROXANAFACILITY TYPE:
850
ADDRESS:701 CHARTER ST, PORT 1,2,3,& 4TELEPHONE:
(650) 482-2407
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 105TOTAL ENROLLED CHILDREN: 78CENSUS: 48DATE:
04/15/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Site Supervisor, Roxana PenaTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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On April 15th, 2025 at approximately 11:40am, Licensing Program Analysts (LPAs) Tapia-Mandujano and Wadhwa conducted an unannounced Case Management- Deficiencies inspection in concurrent with a complaint investigation. LPAs met with Site Supervisor, Roxana Pena regarding the above allegation and explained the purpose of the visit. Present in the facility are Site Supervisor and 13 teachers caring for 48 preschool age children. All adults working at the facility have fingerprint clearance through the Redwood City School District.

On March 20th, 2025 an incident occurred where a child was injured by a toy and that was thrown by another child during outdoor play resulting in some bleeding. Facility failed to follow reporting requirements and did not call in the report within the Department's next working day and during its normal business hours. Incident Report was called in on March 25th, 2025.

Due to the facility not reporting the incident within a timely manner citation was given.

***California Code of Regulations, (Title 22, Div. 12, Ch 3) were cited on this day.

Upon receipt of this report, Licensee shall post the Notice of Site Visit. Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain postings as required, will result in an immediate $100 civil penalty. This report is public and can be reviewed.

After today’s visit, an exit interview was conducted, report was reviewed and copy was provided to Site Supervisor, Roxana Pena.

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
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 04/15/2025 03:52 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 04/15/2025 at 02:24 PM
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: RCSD CHILD DEV SERVICES-HOOVER STATE PRESCHOOL
FACILITY NUMBER: 410518747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2025
Section Cited
CCR
101212(d)

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101212(d): Reproting Requirements: "Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours."

This Requirement is not met by:
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Facility will develop a written plan with clear instructions and procedures for when to report any Unusual Incident Reports.

Plan should include instructions on how to communicate incidents/injuries internally following the chain of command.
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Based on interview and record review, the facility did not comply with the section cited above as the facility failed to call in the incident that occurred on 3/20/25 until 3/25/25 which poses a potential health, safety or personal rights risk to persons in care.
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Facility will also conduct a training to ensure all staff are trained on the updated written policies.

Facility will submit to LPA Tapia-Mandujano both the written plan and the training notes with signatures obtained of all staff present by May 15th, 2025.

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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.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Leslit Tapia-Mandujano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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