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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005024
Report Date: 03/26/2025
Date Signed: 03/26/2025 05:22:08 PM

Document Has Been Signed on 03/26/2025 05:22 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:SAN CARLOS-BELMONT AFTER SCHOOLFACILITY NUMBER:
414005024
ADMINISTRATOR/
DIRECTOR:		VIDUCIC, NANCYFACILITY TYPE:
840
ADDRESS:3100 ST. JAMES ROADTELEPHONE:
(650) 226-5927
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 150TOTAL ENROLLED CHILDREN: 150CENSUS: 113DATE:
03/26/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jessica Cummings / Anthony PerinoTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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On March 26, 2025, Licensing Program Analysts (LPAs) Badger and Tapia-Mandujano met with Director, Anthony Perino and Jessica Cummings for an unannounced annual inspection. Purpose of inspection was explained to the director. Present today were the 2 Directors, 9 staff member and 113 school age children. LPAs reviewed fingerprint clearance and observed that one staff is not fingerprint cleared. Type A citation was given.

The facility is operating within capacity and in compliance with staff child ratio. Facility is located at Fox Elementary School. The facility operates before & after-school program from Monday to Friday 7:00AM to 8:30AM and 12:00PM to 6:00PM; in the detached portable, multipurpose room, and library.

LPAs and Directors toured the facility for health and safety hazards. Classrooms are clean with proper ventilation. There are plenty of age-appropriate toys/games, books, furniture and learning materials all in good repair. Classroom is equipped with two working restrooms, and an additional working restroom in the multi purpose room; all bathrooms have with no running hot water. Facility uses school playground which has a large play structure in good repair. Playground flooring has cushioning in case of falls. There is a large blacktop area and grassy area for children to run and play on. No pools or bodies of water were observed.

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2025
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 03/26/2025 05:22 PM - It Cannot Be Edited


Created By: Jovanna Badger On 03/26/2025 at 03:55 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: SAN CARLOS-BELMONT AFTER SCHOOL
FACILITY NUMBER: 414005024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

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 there was one staff member A1, who has not cleared in the fingerprint database. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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A1 will re-fingerprint and can not return to the facility until she has been fully cleared in the database.

Facility will ensure that all adult fingerprints are cleared prior to being present in a childcare licensing facility.
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.
Daniel J Oquendo
NAME OF LICENSING PROGRAM MANAGER:
Jovanna Badger
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


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: SAN CARLOS-BELMONT AFTER SCHOOL
FACILITY NUMBER: 414005024
VISIT DATE: 03/26/2025
NARRATIVE
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After school program provides an early bird breakfast and snacks for children. Monthly breakfast & snack schedule is posted on kitchen cabinets. Food is properly stored and labeled in cabinets and refrigerator to avoid contamination. Children bring their own labeled water bottles and disposable cups are also available. Facility has water refill stations for all around the school grounds. There is a fully equipped first aid kit located in kitchenette cabinet and two backpacks with first aid supplies, located behind the administrator’s desk. LPA observed medication to be properly stored and labeled in upper kitchen cabinet. All cleaning products, chemicals, and toxins are inaccessible to children and locked in storage cabinets. LPA reviewed sign in/out sheet. Parents sign children in and out in the morning/afternoon. After school care children are signed in by staff. Classroom is equipped with smoke alarms, carbon monoxide detector and fully charged fire extinguisher. Classroom is equipped with working telephones available.

The facility has all necessary paperwork posted, Facility License, Notification of Parent's Rights, Notification of Personal Rights, Car Seat Law, and Emergency Disaster Plan.

LPAs reviewed facility records that included 6 children's records and 5 staff records. LPAs observed children's and staff's records to be complete. At least one staff have an up-to-date CPR & First Aid certificate. All staff have up to date Mandated Reporter Certificate. Last emergency drill was conducted 01/14/2025. Emergency drills are conducted at least once every six months and are properly logged and documented.

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 Evaluator Manual – Regulations Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll free ADA Information Line at (800) 514-0301 (voice)/(800)514-0383(TTY) and link to publication: Commonly Asked Questions about Child Care Centers and ADA, Available at: http://www/adagov/childqanda.htm.

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
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: SAN CARLOS-BELMONT AFTER SCHOOL
FACILITY NUMBER: 414005024
VISIT DATE: 03/26/2025
NARRATIVE
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Director was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

The Director was reminded about the Provider Information Notices (PINs) on the CCLD website. LPA encouraged the Director to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates.

Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

LPA reviewed AB 1207 with the Licensee. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

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. Facility does not have any lead exceedances of 5.5ppb and is in compliance with the Written Directives.

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
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: SAN CARLOS-BELMONT AFTER SCHOOL
FACILITY NUMBER: 414005024
VISIT DATE: 03/26/2025
NARRATIVE
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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.

Based on today's inspection, deficiencies were observed, according to California Title 22, Health and Safety Code of Regulations.

Type “A” deficiency was issued today. Licensee is advised to provide a copy of the Evaluation Report and all Type “A” Deficiencies cited, to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files.

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

Exit interview conducted and report was reviewed with Director, Anthony Perino and Jessica Cummings. Appeal Rights were given.

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC809 (FAS) - (06/04)
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