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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422888
Report Date: 01/20/2026
Date Signed: 01/20/2026 01:14:55 PM

Document Has Been Signed on 01/20/2026 01:14 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:PETERSON, KRISTINAFACILITY NUMBER:
013422888
ADMINISTRATOR/
DIRECTOR:		PETERSON, KRISTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 921-7885
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
01/20/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Kristina PetersonTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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On January 20, 2026, at 11:00 AM, Licensing Program Analyst (LPA) Elimika Woods conducted an Unannounced Annual/Random Inspection and met with licensee Kristina Peterson. LPA disclosed the purpose of the visit and conducted a health and safety inspection, touring the facility both inside and outside. Present during the inspection was the licensee’s fingerprint-cleared assistant. Also present were nine children in care, including eight preschool-age children and one infant. The facility operates Monday through Friday from 7:00 AM to 5:30 PM.

The facility is a single-story home, owned by the licensee, consisting of four bedrooms, two bathrooms, a living room, family room, kitchen, backyard, laundry room, and a two-car attached garage. The home was observed to be clean, orderly, and well maintained, and is equipped with centralized heating and ventilation to ensure the safety and comfort of children. A fireplace located in the living/family room was observed to be blocked to prevent access by children.

On-limits areas include the living room, family room, kitchen, bathroom located on the right side of the hallway, and the backyard.
The designated isolation area is the living room area, away from other children in care.

Off-limits areas include all bedrooms, the laundry area, and the attached garage. These areas are made inaccessible to children by closed and/or locked doors and visual supervision.

At 11:15 AM, LPA inspected the backyard area and confirmed that no pools, hot tubs, or other bodies of water were present, in compliance with childcare licensing regulations. The outdoor play area includes play equipment and outdoor furniture, such as easel boards, small slides with cushioning underneath, a playhouse, tables and chairs, a water table, a digging box, and tricycles. The backyard is fully fenced and free from defects or dangerous conditions. A canopy provides shade and protection from harmful sunlight during outdoor play.

LPA asked the licensee if firearms are stored at the facility, and the licensee stated that firearms are kept in a locked firearm cabinet located in an off-limits area, inaccessible to children in care. At 11:35 AM, LPA Woods inspected the area and confirmed that the firearms were properly secured. At 11:45 AM, LPA asked the licensee if she transports children in care. The licensee stated that she does not provide transportation to children in care.

See LIC 809-C for continuation.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2026
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: PETERSON, KRISTINA
FACILITY NUMBER: 013422888
VISIT DATE: 01/20/2026
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LPA inspected the cabinets in all on-limit areas, including the living room, family room, kitchen, and bathroom, and did not observe any hazardous materials or toxins accessible to children during today’s inspection. LPA tested the dual smoke and carbon monoxide detector located in the hallway and found it to be functioning properly. The home is equipped with a working telephone, a first aid kit, a pull-down fire alarm system, and a fully charged 2A10BC fire extinguisher that meets standards established by the State Fire Marshal.

At 12:00 PM, LPA requested and reviewed the files of three (3) children in care and one (1) staff file. All children’s files contained the required Parent Notification of Additional Children in Care, Identification and Emergency Information, Parent’s Rights, and Medical Consent forms. The staff file contained the required Health Records, Statement Acknowledging the Requirement to Report Child Abuse, and Employee Rights documentation. During the review, LPA Woods also examined the health records of the licensee, staff, and children and determined that the licensee is in compliance with immunization laws applicable to childcare providers.

The licensee conducts and documents fire and disaster drills at least once every six months, with the most recent drill conducted on 10/16/2025. The licensee has completed Health and Safety training, and CPR and First Aid certification is current, with an expiration date of 04/2027. Additionally, the licensee completed Mandated Reporter Training on 03/20/2025. The facility roster was reviewed and accurately reflects both currently enrolled children and those no longer attending the facility. All required forms are posted and visible for public review.

LPA discussed safe sleep regulations with the licensee and reviewed the Child Care Licensing Safe Sleep webpage as an additional resource. LPA also informed the licensee of the importance of checking for recalled infant devices through the United States Consumer Product Safety Commission (CPSC) website and recommended registering all infant devices with the CPSC to receive recall notifications.


Effective August 1, 2003, California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to children’s parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. The licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

See 809-C.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2026
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: PETERSON, KRISTINA
FACILITY NUMBER: 013422888
VISIT DATE: 01/20/2026
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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 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.

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.

The licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Kristina Peterson, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

There are no deficiencies cited today. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Kristina Peterson.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2026
LIC809 (FAS) - (06/04)
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