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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004024
Report Date: 09/07/2022
Date Signed: 09/07/2022 05:09:49 PM


Document Has Been Signed on 09/07/2022 05:09 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:AQUINO, ANNABELLEFACILITY NUMBER:
414004024
ADMINISTRATOR:AQUINO, ANNABELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 734-6514
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:14CENSUS: 1DATE:
09/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Annabelle AquinoTIME COMPLETED:
03:45 PM
NARRATIVE
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On September 7, 2022 at approximately 12:50pm, Licensing Program Analysts (LPAs) Nathan Garcia and Catrina Quimbo conducted an unannounced, case management inspection due to annual fees. Present at the facility are the licensee, Annabelle Aquino and one enrolled child. The purpose of the inspection was explained.

LPAs inspected the home for health and safety hazards. LPAs observed entire home except master bedroom to be currently under construction.

The licensee has a current CPR and 1st aid certificate will expire on 05/2023. Licensee provided LPAs update of individuals who will live in the home once construction is scheduled to complete 09/30/2022 along with their contact information. Per licensee, no individuals are currently living in the home due to construction.

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.


* See next page for deficiency cited today

This report will be emailed to the Licensee, Annabelle Aquino due to low ink on printer.

This report and notice of Site visit and appeal rights were provided to the licensee and must remain posted for 30 days.

Exit interview conducted and report was reviewed with licensee, Annabelle Aquino.
SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/07/2022 05:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: AQUINO, ANNABELLE
FACILITY NUMBER: 414004024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2022
Section Cited

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102416.3
Alterations to Existing Buildings or Grounds (a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed...
This requirement was not met as evidenced by:
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Based on observation and interview, licensee did not inform department of home's reconstruction that includes current day care areas.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2