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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214200011
Report Date: 05/23/2025
Date Signed: 05/23/2025 01:31:45 PM

Document Has Been Signed on 05/23/2025 01:31 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:AYALA, ELVIA GFACILITY NUMBER:
214200011
ADMINISTRATOR/
DIRECTOR:		AYALA, ELVIA GFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 892-5819
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
05/23/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Licensee, Elvia G. AyalaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 5/23/2025, at approximately 10:15AM, Licensing Program Analysts (LPAs) Tran and Ly conducted an unannounced annual inspection at the facility. LPAs met with Licensee, Elvia G. Ayala and informed them of the purpose of the visit. Present during the visit was Licensee, two infants, and one preschool-aged child. The facility’s hours of operation are Tuesday to Friday from 7:30AM to 5:30PM.

Daycare Areas: Playground (side yard), Living Room, Bathroom, and Backyard.
Off-Limits Areas: Large Living Room, Kitchen, Bedrooms, and the rest of the home.

LPAs inspected the facility with Licensee and observed a fully charged fire extinguisher that is at least the size of 2A10BC. There was also a smoke detector and carbon monoxide detector that LPAs tested and verified functionality. All poisons, chemicals, and cleaning detergents were made inaccessible to children. Off-limits areas are properly secured through use of childproof locks and gates. All electrical outlets are either covered or barricaded with furniture when not in use.

LPAs observed a variety of age-appropriate toys and learning materials. Furniture is in good repair and free of sharp edges. Per Licensee, the facility provides snacks and meals. LPAs observed children’s lunch containers brought from home that were not properly labelled. LPAs reminded Licensee that all food brought home must be labelled with each child’s name. Licensee stated she understood. A Type B Deficiency will be cited today as this poses a health and safety risk for children in care. Refer to LIC 809-D for detailed deficiency cited.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2025
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: AYALA, ELVIA G
FACILITY NUMBER: 214200011
VISIT DATE: 05/23/2025
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There are cribs and pack and plays available for napping purposes. LPAs observed blankets, toys, and pillows in the cribs and informed Licensee that cribs must be free of all loose articles per safe sleep regulations. Licensee stated she understood. LPAs observed a bumper cover hung on the outside of the crib. LPAs reminded Licensee that nothing can be hanging on or over a crib. Licensee stated she understood. Per Licensee, all nap bedding is provided and cleaned by the facility. Two Type B Deficiencies will be cited today as these pose a health and safety risk for children in care. Refer to LIC 809-D for detailed deficiencies cited.

In the outdoor play areas, LPAs observed multiple age-appropriate toys for the children. There are multiple shaded areas for children to rest under and resilient padding and grass for children to play on. The property is surrounded by a fence that is at least four feet high. LPAs observed no swimming pools or other similar bodies of water. Per Licensee, there are no firearms or weapons at the facility.

LPAs reviewed one staff file and three children’s files. Licensee has current Pediatric CPR/First Aid training that expires on 6/2026 and Mandated Reporter Training that expires on 6/2025. Licensee has all the required immunizations. Children’s records were observed to be complete with all the necessary documentation. Based on interview and observation, 15-minute sleep logs were not being documented. LPAs reminded Licensee that 15-minute sleep logs are required per safe sleep regulations. Licensee stated she understood. A Type B Deficiency will be cited today as this poses a health and safety risk for children in care. Refer to LIC 809-D for detailed deficiency cited.

The required postings are available for review at the entrance of the Living Room and near the backyard door. LPAs observed the last emergency drill being conducted on 9/24/2024. LPAs reminded Licensee that emergency drills must be conducted at least once every six months. Licensee stated she understood. A Type B Deficiency will be cited today as this poses a health and safety risk for children in care. Refer to LIC 809-D for detailed deficiency cited.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
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: AYALA, ELVIA G
FACILITY NUMBER: 214200011
VISIT DATE: 05/23/2025
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Licensee 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.
Per Licensee, there are no children enrolled with allergies. Incidental Medical Services (IMS) policy was discussed. For IMS information Department. 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 the ADA, available at: on see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the www.ada.gov/childqanda.htm.

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care 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 Licensees. 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. Effective July 1, 2020, Licensees must have proof of completion of EMSA certified lead poison training if applying for a change of location or capacity change to an existing license.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
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: AYALA, ELVIA G
FACILITY NUMBER: 214200011
VISIT DATE: 05/23/2025
NARRATIVE
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LPA encouraged the Licensee to visit the Licensing website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.
To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at:https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.
LPA also informed licensee 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.
Licensee 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.

During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A copy of this report is given to the Licensee with the notice of site visit.
Notice of site visit must be posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

>Type B Deficiencies for loose articles in the cribs, bumper cover hanging on a crib, not having 15-minute sleep logs, and Emergency Drill Logs poses a potential health and safety risk for children in care.
>Technical Violation for not labeling children’s food containers brought from home.

Exit interview and report was reviewed with Licensee, Elvia G. Ayala.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2025 01:31 PM - It Cannot Be Edited


Created By: Nicole Tran On 05/23/2025 at 12:56 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: AYALA, ELVIA G
FACILITY NUMBER: 214200011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee will conduct an emergency drill with the children and log it. A photo of the updated emergency drill log must be sent to LPA Tran by email by 6/06/2025.
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee will remove all loose articles and objects from cribs and pack and plays. A photo of all cribs and pack and plays must be sent to LPA Tran by email by 6/06/2025.
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:
Nicole Tran
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2025 01:31 PM - It Cannot Be Edited


Created By: Nicole Tran On 05/23/2025 at 12:56 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: AYALA, ELVIA G
FACILITY NUMBER: 214200011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee will ensure that there is nothing attached to the side of the crib. A photo of the crib must be sent to LPA Tran by email by 6/06/2025.
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee will document 15-minute sleep logs for all infants under 24 months old. A photo of the sleep logs must be sent to LPA Tran by email by 6/06/2025.
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:
Nicole Tran
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


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