414005273-11-14-2025-05-CC-RWAA-DNEQQS-20251114112249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414005273
Report Date: 11/14/2025
Date Signed: 11/14/2025 11:23:14 AM

Document Has Been Signed on 11/14/2025 11:23 AM - 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:	GUSTAVSON, DANIELLE R.		FACILITY NUMBER:	414005273
ADMINISTRATOR/ DIRECTOR:	GUSTAVSON, DANIELLE R.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 515-9618
CITY:	PACIFICA	STATE: CA	ZIP CODE:	94044
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 6	CENSUS: 0	DATE:	11/14/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Danielle Gustavson		TIME VISIT/ INSPECTION COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/14/2025 at 9:00 AM, Licensing Program Analysts (LPAs) Wadhwa and Gil conducted an announced pre-licensing inspection and met with the applicant, Danielle Gustavson. LPAs were granted entry by the applicant. This pre-licensing pertains to a change of location from 280 Angelita Ave, Pacifica CA 94044 (License # 414005141) to 251 Berendos Ave, Pacifica, CA 94044 and a change of capacity from a large license to a small license. LPAs explained the purpose of the visit to the applicant. Applicant lives in the home with her two minor children. Per applicant, there is one pet cat that lives in the home and is fully vaccinated. Applicant plans to operate Monday through Friday, 12:00 PM to 5:00 PM. Applicant plans to run an after school, bi-lingual, nature-based program for school-age children. Applicant rents this multi-level home consisting of a living room, dining room, kitchen, 3 bedrooms, 2 bathrooms, a garage, a basement that includes a laundry room and a storage room, and a fully enclosed two level backyard. Day Care Areas: Living room (Play Room) on Level 1, Bathroom #1 on Level 2 and both levels of the Backyard. Off-limit Areas: Dining Room, Kitchen, Bedroom #1, #2, #3, Bathroom #2, Basement and Garage. All off-limit areas will be made inaccessible with child safety locks on doors. There is a 6 step-staircase in the living room leading to Level 2 of the home that will remain accessible to children to enable easy access to bathroom #1. Continued on Page 2

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025

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: GUSTAVSON, DANIELLE R.	FACILITY NUMBER: 414005273
	VISIT DATE: 11/14/2025

NARRATIVE

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At approximately 10:00 AM, LPAs and the applicant inspected the entire home for Health and Safety Hazards. The home was observed to be clean with sufficient lighting and ventilation. There are a variety of age-appropriate toys and furniture for children.
All furniture and play equipment were observed to be in good repair. The facility has a smoke and carbon monoxide detector in the home. LPAs tested the detectors located in the living room of the home and observed it to be in working condition. LPAs observed multiple 2A10 BC fully charged fire extinguishers, and a fully stocked first aid kit stored in the high shelves of the living room/ Play Room area. All harmful objects, sharp objects, and toxins are stored in off limits basement of the home.

Applicant states that the home has no weapons or firearms. All Electrical outlets have been covered by outlet covers in all child care areas of the home. The facility has no bodies of water, such as a swimming pool, spa, hot tub, or fishpond. Facility has a two level enclosed back yard area that the Applicant intends to use as outdoor space. The lower level has a patio swing and children’s snack tables. There is a steep flight of stairs that leads to the upper level of the back yard which has multiple play structures. LPAs inspected the upper and lower levels of the backyard and found them to be free of hazards.

At 10:30 AM, LPAs informed the applicant that emergency drills are required every six months and must be documented. Applicant was reminded that NO baby walkers, exer-saucers, jumpers, bouncers, and any similar items to be used for children in care. In addition, booster chairs are only used for the purpose of feeding/eating. Applicant plans to serve dry snacks to children in care. Applicant was also reminded that smoking is prohibited at the Day Care.

Applicant’s has a Mandated Reporter Training Certificate that expires on 11/19/2026 and her Pediatric First Aid/CPR expired in August 2025.

LPAs reviewed with the Applicant the LIC 311D; Forms/Records to Keep In Your Family Child Care Homes, children's forms/records, facility forms/records, and all required postings such as License/Parent's Rights poster/Emergency Disaster Plan and Earthquake Preparedness checklist. In addition, the Entrance Checklist was also provided to the applicant.

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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

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: GUSTAVSON, DANIELLE R.	FACILITY NUMBER: 414005273
	VISIT DATE: 11/14/2025

NARRATIVE

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Applicant 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.

Because the applicant rents/leases the home, proof of landlord notification is required. LPAs reviewed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. Applicant intends to provide care to no more than 6 children at the home.
Per applicant, there are 6 children currently enrolled in the program from the age group of 4 to 7 years old.
Applicant intends to make other arrangements for two of her own school-age children to stay in compliance with ratio and capacity requirements of small day care home.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing 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 Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA discussed the safe sleep regulations with the applicant and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

On this date, 11/14/2025, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

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: GUSTAVSON, DANIELLE R.	FACILITY NUMBER: 414005273
	VISIT DATE: 11/14/2025

NARRATIVE

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Applicant was reminded 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.

The Applicant was encouraged to obtain a copy of regulations and current licensing forms through the Department's website at www.ccld.ca.gov. The Applicant was also reminded of Mandated Reporter Online Training for Child Care Providers (AB 1207) and the additional General Training, and both are available on www.mandatedreporteca.com.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Capacity limits for a small childcare home license were reviewed with the applicant.

Prior to approval of Small Childcare home license: The applicant shall complete and submit verification of the following

- A copy of a current CPR/First Aid certificate.
- A picture of child safety locks of off limit areas of the home.

Exit interview conducted and report was reviewed with the applicant Danielle Gustavson. The report was signed by the Applicant, Danielle Gustavson and provided to her as a printed copy. This report will be kept in the facility file and available for public review upon request. Desk duty is available Monday - Friday, 8:00 am – 5:00 pm (650) 266-8800. Website for Forms and Regulations: www.cdss.ca.gov.

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

LIC809 (FAS) - (06/04)

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