410518531-4-8-2025-05-CC-DALO-DFJSQ9-20250408140422

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 410518531
Report Date: 04/08/2025
Date Signed: 04/08/2025 02:05:07 PM

Document Has Been Signed on 04/08/2025 02:05 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:	NAVARRETE, GLORIA L.		FACILITY NUMBER:	410518531
ADMINISTRATOR/ DIRECTOR:	NAVARRETE, GLORIA L.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 873-6956
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 12	CENSUS: 6	DATE:	04/08/2025
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Danilo Navarrete		TIME VISIT/ INSPECTION COMPLETED:	02:20 PM

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 4/8/2025 at approximately 10:30AM, Licensing Program Analysts (LPAs) Diana Alvarado and Jonathan Tse conducted an unannounced annual visit at the facility. LPAs met with helper, Danilo Navarrete (H1), and explained the purpose of the visit. Present during the visit was H1, another helper, four preschool age children, and two infants. Licensee was not present during the visit. Per H1, Licensee was on vacation. The facility’s operating hours are from 7:00AM to 6:30PM. Daycare Areas: Family Room, Bedroom #1, Bedroom #2, Bathroom #1, and Front Yard. Off-limits Areas: Kitchen, Bedroom #3, Master Bedroom, Living Room, Garage and Backyard. LPAs and H1 inspected the home for any health or safety hazards. The home is equipped with a fully charged 2A10BC fire extinguisher. There are carbon monoxide detectors that were demonstrated to be operational during the visit. There is a fireplace in the Family Room that has been barricaded to be inaccessible. Electrical outlets are covered or blocked by furniture when not in use. LPAs observed that cleaning detergents and other chemicals were accessible to children in the Bathroom. There was a cleaning spray present on the Bathroom floor and cleaning detergents present in the Bathroom cabinet. The childproof latch in the Bathroom cabinet was observed to be broken. LPAs advised that all chemicals and cleaning detergents be removed during the visit. H1 stated that they understood and removed all chemicals and cleaning detergents from the Bathroom. LPAs observed there to be age-appropriate toys and learning materials present. Furniture is age-appropriate and free of rough or sharp edges. Children nap in cribs and beds that are provided by the facility. Per H1 the facility provides breakfast, lunch, AM/PM snack, and dinner as needed. Continued on Page Two

Ali Zebila	TELEPHONE: (650) 730-4140
Diana Alvarado	TELEPHONE: 650-266-8800
	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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: NAVARRETE, GLORIA L.	FACILITY NUMBER: 410518531
	VISIT DATE: 04/08/2025

NARRATIVE

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LPAs observed an exersaucer to be present in the facility. H1 removed the exersaucer from the daycare areas during the visit. LPAs observed that infants were napping in cribs with blankets and other loose objects. LPAs advised H1 regarding the following safe sleep regulations:

1) Cribs are to be kept free of objects and other loose articles, including blankets.
2) There shall be no objects hanging on the side of or attached to the side of the crib.
3) Infants are to be moved to cribs once they fall asleep.
4) Pacifiers are not to have anything attached while in use.

LPAs advised that car seats are to be used only for transportation. LPAs observed that a bookshelf in Bedroom #2 was secured to the wall with an elastic cord. LPAs observed the bookshelf to not be stable. LPAs advised that the bookshelf must be secured and in good repair. H1 stated that they understood.

LPAs observed the Front Yard to contain toys and play equipment. LPAs observed that chemicals, broken toys, and trash bags were present in the Front Yard. LPAs advised that the Front Yard must be kept free of debris and other loose articles. The Front Yard is enclosed by a fence. There are no swimming pools or other similar bodies of water present. Per H1, there are no firearms or weapons present in the home.

LPAs reviewed three staff records, six children’s records, and facility records. There are no helpers present with current Pediatric First Aid/CPR training from an approved training vendor. Mandated Reporter Training is not on file. LPAs advised that all personnel providing care must have staff files available for review.

Children’s records were observed to be complete. LPAs advised that an Individual Infant Sleeping Plan (LIC9227) must be maintained for all children under 12 months of age. Infant sleeping logs are to be maintained for all infants (0-24 months of age).

LPAs advised that a facility roster of enrolled children must be maintained. Per H1, emergency drills have not been conducted or logged. LPAs advised that emergency drills must be conducted and logged at least once every six months.

Continued on Page Three

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 730-4140
LICENSING EVALUATOR NAME: Diana Alvarado	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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: NAVARRETE, GLORIA L.	FACILITY NUMBER: 410518531
	VISIT DATE: 04/08/2025

NARRATIVE

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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.

Facility representative 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.

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

Continued on Page Four

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 730-4140
LICENSING EVALUATOR NAME: Diana Alvarado	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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: NAVARRETE, GLORIA L.	FACILITY NUMBER: 410518531
	VISIT DATE: 04/08/2025

NARRATIVE

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Facility representative 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, facility representative confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

See LIC809-D for deficiencies cited today regarding infant safe sleep, physical plant, and staff records. See LIC9102-TV for technical violations issued today regarding infant safe sleep and records. Appeal rights were provided and explained to H1. A notice of site visit was provided and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Danilo Navarrete.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 730-4140
LICENSING EVALUATOR NAME: Diana Alvarado	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/08/2025 02:05 PM - It Cannot Be Edited

Created By: Diana Alvarado On 04/08/2025 at 01:16 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: NAVARRETE, GLORIA L.	FACILITY NUMBER: 410518531
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)

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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not maintaining a bookshelf in Bedroom #2 in good repair which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	LPAs observed a bookshelf in Bedroom #2 to not be fully secured. Licensee shall repair the bookshelf so that it is stable and not at risk of falling.

Type B

Section Cited

CCR

102417(g)(4)

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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having cleaning detergents accessible to children in the Bathroom which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	H1 removed all cleaning detergents from the Bathroom during the visit. This deficiency shall be cited and cleared the day of the visit, 4/8/2025.

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:

TELEPHONE: (650) 730-4140

	Diana Alvarado
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: 650-266-8800

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

Page: 6 of 15

Document Has Been Signed on 04/08/2025 02:05 PM - It Cannot Be Edited

Created By: Diana Alvarado On 04/08/2025 at 01:16 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: NAVARRETE, GLORIA L.	FACILITY NUMBER: 410518531
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not keeping cribs and play yards free of loose articles and objects, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Licensee shall maintain all cribs and play yards free of blankets and loose objects. A follow-up visit shall be conducted to verify compliance.

Type B

Section Cited

CCR

102417(a)

Operation of A Family Child Care Home

(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by not being present in the home for more than 20 percent of the facility's operating hours which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Licensee shall report to the Regional Office when they are going on vacation. Licensee shall submit a signed and written statement acknowledging and understanding this regulation.

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:

TELEPHONE: (650) 730-4140

	Diana Alvarado
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: 650-266-8800

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/08/2025 02:05 PM - It Cannot Be Edited

Created By: Diana Alvarado On 04/08/2025 at 01:16 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: NAVARRETE, GLORIA L.	FACILITY NUMBER: 410518531
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not having current Mandated Reporter Training on file for each staff member which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Licensee shall ensure that all staff members providing care for children complete Mandated Reporter Training by 5/2/2025. Proof of completion shall be submitted to LPA via email by 5/2/2025.

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having Pediatric First Aid/CPR training completed by an approved training program which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Licensee shall ensure that at least one staff member present in the facility has current Pediatric First Aid/CPR training from the American Red Cross, American Heart Association, or an EMSA approved training program. Licensee shall submit proof of enrollment in a class by 5/2/2025.

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:

TELEPHONE: (650) 730-4140

	Diana Alvarado
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: 650-266-8800

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

Page: 8 of 15

Document Has Been Signed on 04/08/2025 02:05 PM - It Cannot Be Edited

Created By: Diana Alvarado On 04/08/2025 at 01:16 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: NAVARRETE, GLORIA L.	FACILITY NUMBER: 410518531
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416.1(d)

Personnel Records

(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not maintaining files for all staff members present which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Licensee shall maintain a current personnel file for all staff members providing care for children. An Entrance Checklist (LIC126) was provided for reference.

Type B

Section Cited

CCR

102425(j)(2)(D)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not logging infant sleep checks every 15 minutes which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Infant sleep logs shall be maintained for all infants (0-24 months). Sample sleeping logs were provided during the visit. The facility shall maintain infant sleeping logs and have them available for review. A follow-up visit shall be conducted to verify compliance.

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:

TELEPHONE: (650) 730-4140

	Diana Alvarado
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: 650-266-8800

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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