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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004456
Report Date: 10/15/2025
Date Signed: 10/15/2025 04:30:18 PM

Document Has Been Signed on 10/15/2025 04:30 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:2ND GENERATION CABOT (PS)FACILITY NUMBER:
414004456
ADMINISTRATOR/
DIRECTOR:		HOLLY ANDERSONFACILITY TYPE:
850
ADDRESS:342 ALLERTON AVETELEPHONE:
(650) 225-3666
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 264TOTAL ENROLLED CHILDREN: 264CENSUS: 12DATE:
10/15/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:26 PM
MET WITH:Holly AndersonTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On October 15, 2025 at approximately 1:30pm, Licensing Program Analyst (LPA) Alvarado conducted an unannounced, case management visit to 2nd Generation Cabot (Preschool) in regard to an incident that was self-reported to the facility on October 2nd, 2025. LPA met with Facility Director, Holly Anderson(D1), and explained the purpose of the visit. LPA Alvarado along with (D1) Conducted a Health and safety inspection for the Preschool license.

“Penguins” Classroom is located in the Sea Bird House, which was observed to have twelve preschool children (Ages 2-3) present and two staff members during todays inspection. LPA along with (D1) toured the outdoor space area where the initial incident occurred. LPA observed age-appropriate toys and materials. outdoor play area was observed to be free of debris and other loose articles. Outdoor play areas are enclosed by fences that are at least four feet high. LPA did recommend that additional foam cushion or mats be brough out when children want to explore more challenging activities, that can capture small falls.

LPA received during todays inspection a copy of the attendance report, for (C1) as well as the staff attendance report reflecting the day the incident occurred, LPA also received a daily schedule and email documentation with (C1) parents. During today’s visit at approximately 2:20pm, LPA conducted interviews with two staff members (S1) and (S2) to gather more information regarding the self-reported Incident that occurred with (C1) On October 1st, 2025.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Diana Alvarado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
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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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: 2ND GENERATION CABOT (PS)
FACILITY NUMBER: 414004456
VISIT DATE: 10/15/2025
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Incident occurred on October 1st, 2025 where (C1) was playing on and attempting to lay flat on a small to medium size beach ball. (C1) lost his balance and rolled off, landing on his right side of his arm. Incident was an accident as (C1) lost balance. Staff assisted the child immediately and did not see any visible or physical marks on (C1). Staff continued to observe (C1) and Parents were notified and asked to be kept updated if (C1) had any additional discomforts. (C1) continued the rest of the day such as restroom use, eating and napping freely. (C1) returned to school the following day, had a doctor’s appointment that morning and returned back to school. (C1) was advised by the pediatrician to remain in a sling for six weeks due to a right clavicle fracture. (C1) has remained in school with restrictions on strenuous activities.

Based on today's inspection 10/15/2025, deficiencies were not observed, according to California Title 22, Health and Safety Code of Regulations. No deficiencies cited on this day.

Appeal Rights were provided to facility Director, Holly Anderson. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Facility representative, Holly Anderson
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Diana Alvarado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
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