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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002634
Report Date: 04/03/2025
Date Signed: 04/03/2025 03:37:22 PM

Document Has Been Signed on 04/03/2025 03:37 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:BUSTILLO, FLOR MARIAFACILITY NUMBER:
384002634
ADMINISTRATOR/
DIRECTOR:
BUSTILLO, FLOR MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 410-7785
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
04/03/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Licensee, Flor Maria BustilloTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On April 3, 2025 at approximately 1:15pm, Licensing Program Analyst (LPA) Melissa Zaragoza conducted an unannounced, annual inspection. LPA was greeted and granted access by licensee, Flor Maria Bustillo. At the entrance the licensee was explained the purpose of the inspection. Present during LPA's visit included the licensee, 2 staff assistants, and 4 children (preschool age).

Hours of operation are Monday through Friday, 8:00am to 4:00pm. Licensee lives in a one- level home. All adults living in the home and staff present, working with children have fingerprint clearance on file.

The DAY CARE AREAS are the kitchen, bathroom, living room, bedroom #1, and bedroom #2. The OFF-LIMIT AREAS are bedroom #3, laundry area, and the backyard. All off-limit areas are made inaccessible to children in care with child safety gates and child safety door handles.

LPA toured day care areas of home with the licensee. LPA observed home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in good condition. LPA observed electrical outlets to be made inaccessible with children in care with outlet covers. Cleaning supplies, poisons, and hazardous materials are stored and locked behind child safety gates, and homes high shelves.

Home is equipped with a fully charged fire extinguisher and a smoke and carbon monoxide detector. Smoke and carbon monoxide detectors were tested during visit and were observed to be in working condition. LPA observed trash cans with tight fitted lids. There are no pools, and bodies of water in the premises.

Napping area was observed to be equipped with playpens and mats for napping children. LPA observed children to have their own individual playpen and mat. Playpens were observed to have a tight fitted sheet, and to be free of any loose article. Per licensee, they provide the sheets and blankets. Sheets and blankets are washed every Friday by the licensee. LPA observed 15 min sleep logs to be maintained and documented.

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Marie RodriguezTELEPHONE: (650) 266-8827
Melissa ZaragozaTELEPHONE: 650-266-8800
DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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: BUSTILLO, FLOR MARIA
FACILITY NUMBER: 384002634
VISIT DATE: 04/03/2025
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Bathroom was observed to be in proper working condition. LPA also observed 1 changing table used for diapering children. There is appropriate sanitation and toileting equipment for children in care. LPA observed bathroom to have child safety locks installed in cabinets. Per licensee, children’s families provide diapers and wipes for enrolled children.

Children eat in the kitchen. Children were observed to have appropriate tables and highchairs for eating. Per licensee, they provide a food service, of breakfast, morning snack, and afternoon snack. Per licensee, parents provide children lunch. Per licensee, they are aware of children’s allergies and dietary restrictions. LPA observed knives to be made inaccessible to children, and cabinets in the kitchen to have child safety locks installed.

LPA reviewed 6 children’s record which was complete. LPA reviewed licensee’s records and staff assistant records, which were complete. The license has a current CPR/First Aid certification and Mandated Reporter certification. Licensee’s CPR/First Aid certification expires on 01/2026, and Mandated Reporter certification expires on 10/02/2026.

Emergency disaster drills are conducted and are appropriately documented. Last disaster drill was conducted September 2024. LPA observed licensing documentation to be properly posted, made available for review. Facility maintains a childcare roster that was also made available for review. Per licensee, there are no weapons or firearms in the home.

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.

Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

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SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8827
LICENSING EVALUATOR NAME: Melissa ZaragozaTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
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: BUSTILLO, FLOR MARIA
FACILITY NUMBER: 384002634
VISIT DATE: 04/03/2025
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.

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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

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, Flor Maria Bustillo, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed a Megan’s Law search on 04/03/2025.

No deficiencies were cited during today’s visit.

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

Exit interview conducted and report was reviewed with the licensee, Flor Maria Bustillo.

report was translated in Spanish.
SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8827
LICENSING EVALUATOR NAME: Melissa ZaragozaTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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