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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004018
Report Date: 11/06/2025
Date Signed: 11/06/2025 11:01:05 AM

Document Has Been Signed on 11/06/2025 11:01 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:HOLY ANGELS PRESCHOOLFACILITY NUMBER:
414004018
ADMINISTRATOR/
DIRECTOR:		MERLE S LEBAQUINFACILITY TYPE:
850
ADDRESS:20 REINER STREETTELEPHONE:
(650) 303-1478
CITY:COLMASTATE: CAZIP CODE:
94014
CAPACITY: 28TOTAL ENROLLED CHILDREN: 28CENSUS: DATE:
11/06/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:31 AM
MET WITH:Sister Merle LebaquinTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On November 6th, 2025 at approximately 8:30 AM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced, annual inspection. LPA met with the site supervisor, Sister Merle Lebaquin, and explained the purpose of the inspection. Present during LPA's visit included site supervisor, teacher's aide, and 12 preschool age children. Facility is operating within capacity limits and ratio during LPA's visit. All staff present have fingerprint clearance on file.

Hours of operation are Monday to Friday 7:45 AM to 3:00 PM. Preschool program operates at Holy Angels Elementary School in Classroom A (main classroom) and Classroom B. Per site supervisor, Classroom B is utilized for lunch time and rainy day use only.

LPA and site supervisor inspected facility, indoors and outdoors, for health and safety hazards. Program operates out of 2 classroom and an outdoor area only. LPA observed classrooms to be clean, equipped with age appropriate toys, materials, and furniture. LPA observed electrical outlets to be made inaccessible with child safety outlet covers. Storage for children's belongings are located outside the classrooms. LPA observed facility to have sufficient cots for all children in care. Per site supervisor, parents or authorized representatives take sheets and blankets home weekly to be laundered. Per site supervisor, cots are sanitized daily, after each use.

LPA observed facility has an installation of a fire alarm system throughout the building. LPA observed a carbon monoxide detector in main classroom. LPA tested detector in main classroom, which was in working condition. Facility has a fully stocked and accessible first aid kit backpack in each classroom. Facility has multiple fully charged fire extinguishers. All poisons, cleaning solutions and hazardous materials are stored inaccessible to children on facility's high shelves.

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NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Janet Gil
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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: HOLY ANGELS PRESCHOOL
FACILITY NUMBER: 414004018
VISIT DATE: 11/06/2025
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LPA observed the children's bathroom to be clean and in proper working condition. Facility does not provide any food service. Children's families provide food that is brought to facility daily and stored in children's cubbies. Per site supervisor, program does not handle food or prepare children's food. Drinking water is available to enrolled children indoors and outdoors with individual water bottles that can be refilled on site through filtered water dispenser (if needed). LPA did not observe an accessible drinking fixture inside or outside preschool program areas.

Outdoor area is fully enclosed and has age appropriate toys and materials that were in working condition. LPA observed play structure to contain padding underneath.LPA observed no pools, spas, or bodies of water in day care areas.

Children are signed in and out of facility through a paper system by the entrance of the facility. All children were signed in correctly during LPA's visit for that date. Facility has license documentation and information properly posted and available for review. Preschool program conducts drills every month. Last conducted disaster drill was on 10/08/2025.

LPA reviewed 6 children's files and 2 staff records. Children's records were complete. Site supervisor has a valid CPR/First Aid certificate that will expire in 08/2027. Director also has proof of required immunization that were made available for review. Mandated Reporter Training Certification for the site supervisor expired on 10/2025. LPA reminded site supervisor to renew certification. A technical violation was provided.

Facility 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.

Director is aware that all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. LPA observed the completed certificate on file. LPA encourages the director to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates.

Director was reminded that all adults 18 and over, 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 Child Care Center. 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.

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NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Janet Gil
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: HOLY ANGELS PRESCHOOL
FACILITY NUMBER: 414004018
VISIT DATE: 11/06/2025
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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/inspection-process.

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 PIN 22-02-CCP. 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 are available at: https://www.ada.gov/resources/child-carecenters/

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.

Program does not provide or offer a food service. Children's families provide food that is brought to facility daily and stored in children's cubbies. Per site supervisor, program does not handle food or prepare children's food. Site supervisor submitted a letter of attestation to department November 2023, attesting water fixtures on site are not used for drinking or food preparation. Water fixtures on site are for hand washing only. Per site supervisor, she is still waiting for the attestation waiver request.

No deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the site supervisor, Sister Merle Lebaquin.
NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Janet Gil
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
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