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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002634
Report Date: 04/24/2025
Date Signed: 04/24/2025 01:30:34 PM

Document Has Been Signed on 04/24/2025 01:30 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:SBPSD ALLEN ELEMENTARY SCHOOL & PRESCHOOLFACILITY NUMBER:
414002634
ADMINISTRATOR/
DIRECTOR:		ITZA GONZALEZFACILITY TYPE:
850
ADDRESS:500 ACACIA AVENUETELEPHONE:
(650) 624-3158
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 84TOTAL ENROLLED CHILDREN: 56CENSUS: 34DATE:
04/24/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Itza GonzalesTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 4/24/25 at approximately 9:00 AM, Licensing Program Analysts (LPAs) Wadhwa and Van arrived at the facility to conduct an unannounced annual inspection. LPAs met with Office Manager Amparo (O1) and explained the purpose of the inspection. Director Itza Gonzalez arrived a few minutes later. Present in the facility today were the Director, 8 staff caring and supervising a total of 6 toddlers and 28 preschoolers. All facility’s staff members have had their criminal background checks cleared by the San Bruno Park School District.

Facility operates out of 4 rooms: 3H, 4H, 5H and 6H. Room 4H is currently not in use as a classroom but is used as a Sensory Room occasionally. LPAs inspected facility with the Director for health and safety hazards. LPAs observed classrooms to be clean and equipped with age appropriate toys and materials. Storage for children’s belongings is provided inside the classrooms in their individual cubbies. The facility has a fully charged, fire extinguishers located inside each of the classrooms. The classrooms have a smoke and carbon monoxide detector installed as well as emergency backpacks and multiple first aid kits available inside the classroom. The facility maintains an Emergency Contact information packet in each classroom. Per Director, there is one child with allergies requiring an EpiPen however, it was not available for review today. Per Director, the family was reminded but has not provided it to the facility as yet. As a result, a technical violation was issued. LPAs advised the director to obtain the Epipen from the parent as soon as possible. Per Director, there are currently no children with prescribed medication enrolled at the facility.

LPAs observed every classroom had the required documents posted for review including the license, waiver for outdoor playground, notification of parental rights, notification of personal rights, car seat law, emergency disaster plan, weekly menu, and daily activities schedule.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
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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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: SBPSD ALLEN ELEMENTARY SCHOOL & PRESCHOOL
FACILITY NUMBER: 414002634
VISIT DATE: 04/24/2025
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The facility provides food service to preschool children in classrooms 5H and 6H. The food is prepared at Allen Elementary School and is dropped off at the facility twice daily, once at breakfast and once at lunch. Toddlers in classroom 3H bring their own lunch and snacks from home. Parents provide a water bottle from home that can be refilled at the facility as needed.

Outdoor area appears to be clean and orderly. There are a variety of outdoor equipment that are in good working condition. The playgrounds are equipped with a layer tanbark to reduce any impact from accidental falls. There are no pools or bodies of water on the premises. Children are signed in and out of facility using a sign-in sheet. LPAs reviewed the sign in sheets and found it to be complete with full signatures and all children present today were accounted for. Per Director, earthquake and fire drills are conducted monthly and were found to be properly logged. The last fire drill was conducted on 4/15/2025 and the last earthquake drill was done on 4/17/2025.

LPAs reviewed facility records that included 5 children’s files and 5 staff records. Children's files have a record of emergency identification information as well as required immunizations. LPAs observed some staff to be missing immunizations records, as a result a technical violation was issued.

Director was reminded that all adults 18 and over, 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 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.

LPAs reminded the Director that all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. LPAs encourages the director to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates.
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Document Link IconQuestions about Child Care Centers and the ADA are available at https://www.ada.gov/resources/child-care-centers/.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
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: SBPSD ALLEN ELEMENTARY SCHOOL & PRESCHOOL
FACILITY NUMBER: 414002634
VISIT DATE: 04/24/2025
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CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES:
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.

For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

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

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

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.

There were no deficiencies cited at this time under CCR, Title 22, Div. 12, Chapter 3. A copy of today's report was given to the Director. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director, Itza Gonzalez.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
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