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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004405
Report Date: 12/16/2025
Date Signed: 12/16/2025 01:58:06 PM

Document Has Been Signed on 12/16/2025 01:58 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:LOS LISTOS PRESCHOOLFACILITY NUMBER:
414004405
ADMINISTRATOR/
DIRECTOR:		SEGURA, ROSALVAFACILITY TYPE:
850
ADDRESS:490 MIRAMONTE AVE.TELEPHONE:
(650) 240-3233
CITY:HALF MOON BAYSTATE: CAZIP CODE:
94019
CAPACITY: 55TOTAL ENROLLED CHILDREN: 49CENSUS: 23DATE:
12/16/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Site Supervisor, Graciela Krabbenschmidt TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On December 16th, 2025 at approximately 9:15AM, Licensing Program Analyst (LPA) Alvarado arrived at the facility. LPA checked in with the Main Office and met with Site Supervisor, Graciela Krabbenschmidt (S1). The purpose of inspection was explained which was for an annual inspection. Facility Director, Rosalva Segura (D1) also joined the inspection. Present in the Facility is (S1) and eight staff members supervising a total of 23 children (Preschool age). The facility is operating within staffing and ratio requirements on this day. Facility has fingerprint clearance that is done through the Cabrillo Unified School District.

LPA along with (S1) inspected the facility for any health or safety hazards, Indoors and Outdoors. Facility is located on Hatch Elementary School. The Facility has three classrooms: Facility is currently licensed in portable K5, K6, and K7. Facility was reminded that any off-limit areas, must be approved by the department prior to usage. Currently the facility is only utilizing Portables K5 and K6. Facility also uses the Outdoor Play Area, which is also a fenced outdoor play area within the facility Portables. No Pools, hot tubs, spas, or similar bodies of water present in the facility.

Facility Hours of operation are in two sessions AM and PM sessions, that are from Monday-Friday 8:30AM-11:45AM and 2:00-5:00PM. Per (S1), facility offers breakfast, AM and PM snack provided by the school district. Per (S1), water services are readily available. Children bring their own water bottles from home and facility have small disposable cups available if needed. Facility has filtered water services that are available in dispensers and receives deliveries once a month. Per (S1) there are no weapons or firearms in the facility. Facility uses physical paper and logs to ensure that parents sign in and out.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Diana Alvarado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2025
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: LOS LISTOS PRESCHOOL
FACILITY NUMBER: 414004405
VISIT DATE: 12/16/2025
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LPA observed two functioning toilets and two functioning sinks in the facility. Facility Building is equipped with fully charged fire extinguishers. Fire alarm systems and Carbon Monoxide Detector in the facility. Which get serviced when the school Districts get serviced. Facility has a Fully equipped First Aid Kit. Electrical outlets are childproof and inaccessible. LPA observed in classroom K5 the bathroom sink that was loose, and (S1) stated that that a work order was being placed. LPA also observed, disinfecting wipes that were not locked, and no children present in the area. LPA reminded (S1) that the facility must ensure to make Poisons, cleaning detergents, and other chemicals inaccessible to children in care. LPA observed in K6 a broken outlet plate, and (S1) stated that a work order also has been placed. Sign in and out was also discussed with (S1) as a few signatures were missing for children who were present.

(S1) guided LPA outdoors to inspect the Play Area. Outdoor play area has sufficient shading and has fake grass for safe landing zones. LPA observed the outdoor play areas to be free of debris and other loose articles. There are age-appropriate toys and equipment present. Each outdoor play area is enclosed by a fence that is at least four feet high.

LPA reviewed 4 staff files, a few staff members had immunizations for review. At least one staff Member has current Pediatric First Aid/CPR training that Expires 2/2026. Staff have qualifications for review. Three Staff members do not have updated Mandated Reporter Training on File. LPA reviewed 6 children files that were complete. LPA observed one file that was missing proof of immunizations. Fire drills have been conducted and documented, that are followed along with the Cabrillo Unified School District, that are conducted monthly. (S1) that Emergency must be conducted and logged at least once every six months. All required postings were observed to be posted and accessible for review upon entry to the facility, LPA advised on a few that needed to be posted.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Diana Alvarado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
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: LOS LISTOS PRESCHOOL
FACILITY NUMBER: 414004405
VISIT DATE: 12/16/2025
NARRATIVE
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Facility representative 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.

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 as specified in Health and Safety Code section 1597.16.

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.). LPA verified that the lead testing was completed in accordance to the Written Directives (Interim Licensing Standards) outlined in PIN 21-21.1-CCP.

LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information (https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information)

• CCC DID NOT COMPLETE TESTING PRIOR TO THEIR DEADLINE

Facility tested late for Lead, with a sample date on 10/9/2024 and Load Date of 10/17/2024. Facility will be cited for lead and cleared during todays inspection regarding Lead Testing.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Diana Alvarado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
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: LOS LISTOS PRESCHOOL
FACILITY NUMBER: 414004405
VISIT DATE: 12/16/2025
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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/.

facility representative 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.

See LIC 809-D for deficiencies being cited today on 12/16/2025 under the California Code of Regulations, Title 22, Division 12, Chapter 1. Regarding Physical Plant and Staff Records.

See LIC9102-TV for Technical Violation issued today regarding Children’s Records.

See LIC9102-TA for Technical Advisory issued today regarding Physical Plant and Children’s Records.

Appeal Rights were provided to facility representative, Graciela Krabbenschmidt .

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

Exit interview conducted and report was reviewed with the facility representative, Graciela Krabbenschmidt
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Diana Alvarado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2025 01:58 PM - It Cannot Be Edited


Created By: Diana Alvarado On 12/16/2025 at 12:48 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: LOS LISTOS PRESCHOOL
FACILITY NUMBER: 414004405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of one identifiers, the facility tested after the written directives due date which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2025
Plan of Correction
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Facility will be cited and cleared during todays inspection as the facility has a sample date of 10/9/2024 and load date of 10/17/2024. Facility is now in compliance with lead testing requirements.
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 interview and record review, the licensee did not comply with the section cited above in three of the three persons who did not have updated Mandated Reporter Trainings which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2026
Plan of Correction
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Facility will have staff complete the Mandated Reporter Trainings; Facility will submit via email to LPA Alvarado proof of updated and completed mandated reporter trainings by 01/09/2026. LPA will also conduct a follow up inspection with the facility to ensure that the mandated reporter trainings are being maintained.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Diana Alvarado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2025 01:58 PM - It Cannot Be Edited


Created By: Diana Alvarado On 12/16/2025 at 12:48 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: LOS LISTOS PRESCHOOL
FACILITY NUMBER: 414004405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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, Facility has not maintained updated Personnel Records for staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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LPA provided facility representative the LIC 125 Facility Entrance Checklist that show all that is required. Facility will submit by 01/30/2026 files for all staff members to be complete. LPA Alvarado will also conduct a follow up inspection to ensure that files are complete.
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.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Diana Alvarado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


LIC809 (FAS) - (06/04)
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