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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410518747
Report Date: 12/02/2025
Date Signed: 12/02/2025 03:32:26 PM

Document Has Been Signed on 12/02/2025 03:32 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: 67CENSUS: 40DATE:
12/02/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Site Supervisor, Roxanna PenaTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On December 2nd, 2025 at approximately 11am, Licensing Program Analyst, (LPA) Tapia-Mandujano arrived at the facility for a Case Management-Incident inspection. LPA met with Site Supervisor, Roxanna Pena. Program Director, Jennifer Pare arrived during inspection. The purpose of today's inspection was explained, and it was in response to an Unusual Incident Report that was called in on November 21st, 2025 and received by the department on November 24th, 2025.

Facility operates in Classrooms #1,2,3, and 4. Present in the facility are Site Supervisor and 12 staff supervising 40 preschool-age children. During today’s inspection, facility is operating within capacity limitations. All adults in the facility are fingerprint cleared through the Redwood City School District. LPA inspected classrooms for Health and Safety Hazards.

The facility self-reported an incident that occurred on November 19th, 2025. The incident involved lack of supervision that resulted in a child being left unsupervised outside of the classroom. Per interviews and record review of incident received, children were playing in the outdoor playground. Per interviews, children were transitioning from outdoor to inside and one child was left outside within the outdoor playground for approximately 3 minutes. Per interviews, the door was completely closed. Once staff realized the child was left outside the child rejoined the rest of the group inside the classroom. Parents of unsupervised child were notified.

During today's inspection, LPA inspected the area where the incident took place. LPA spoke with Site Supervisor and Program Director of the actions that were taken. Due to a potential health and safety risks for lack of supervision, a Type B deficiency has been issued. Please see LIC 809D for more details.

This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit. An exit interview was conducted and report was reviewed with Site Supervisor, Roxanna Pena.

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2025
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 12/02/2025 03:32 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 12/02/2025 at 02:57 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: 12/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2026
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision: (a) "The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation."

This requirement was not met as evidenced by:
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Facility will submit proof that the door to the outdoor playground has been fixed.

Facility will submit a written policy for supervision that includes the policy/steps to be taken specifically during transitions.
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Based on interview and record review, the facility did not comply with the section cited above as facility self-reported that there was a child left alone outside during transition back to the classroom from the outdoor play yard, which poses a potential health, safety or personal rights risk to persons in care.
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Facility will have training for all staff to be made aware of policy/steps to be taken during transitions.

Facility will submit agenda with copies of staff acknowledging the policies/steps to be taken during transitions to LPA Tapia-Mandujano by January 9th, 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: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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