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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004024
Report Date: 10/12/2022
Date Signed: 10/12/2022 04:46:56 PM


Document Has Been Signed on 10/12/2022 04:46 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: 0DATE:
10/12/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Annabelle AquinoTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Medlin met with facility representative for this case management visit due to major home construction/renovation. LPA toured the entire home including areas that will be used for daycare purposes and off limits areas. The updated sketch will indicate these areas. Per licensee, the following individual reside in the home: herself, her parents, adult son (R1), and adult daughter (R2). The areas indicated on the facility sketch, and as directed per licensee, are fine for daycare use. The off limits area are: all bedrooms, garage, the bathroom inside master bedroom, and gated off area in the backyard. There is a shed in the backyard that licensee states is used for storage.

Due to a violation of criminal record clearance an immediate civil penalty is hereby assessed for $500 which equals $100/day for 5 days. Subsequent criminal record clearance violations are subject to a $3000 penalty.

The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 12, Chapter 1.

This report is reviewed with Licensee and a copy of this report must be made available for public review upon request. Due to Type A violations, this report and violations must be given to all current parents/guardians and newly enrolled families for the next 12 months and documented on the LIC 9224 and returned to each child's file.


Notice of site visit posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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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Document Has Been Signed on 10/12/2022 04:46 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: 10/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2022
Section Cited

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CRIMINAL RECORD CLEARANCE: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department.
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This requirement is not met as evidence R1 is not listed on the facility personnel roster for fingerprints. This is an immediate health and safety risk.

An immediate civil penalty of $500 is assessed today.
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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) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
LIC809 (FAS) - (06/04)
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