<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214002725
Report Date: 07/22/2026
Date Signed: 07/22/2026 04:18:08 PM

Document Has Been Signed on 07/22/2026 04:18 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:JOHNSON, ANNA KAJSAFACILITY NUMBER:
214002725
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
07/22/2026
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:43 PM
MET WITH:Anna Kajsa JohnsonTIME VISIT/
INSPECTION COMPLETED:
04:35 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 July 22, 2026, Licensing Program Analyst (LPA) Garcia conducted an unannounced case management inspection to increase of capacity and met with licensee, Anna Kajsa Johnson. Licensee requested to increase from a Small to a Large Family Child Care. Fire Clearance was received by the department from Tiburon Fire Department on July 16, 2026. Present in the home is the licensee, 2 helpers and 5 children in care. All adults living and working in the home have fingerprint clearance and are associated to the facility. Licensee has at least one year of FCCH experience.

Licensee rents this 4 bedroom and 3.5 bathroom, home with a back yard front yard and downstairs lounge. The hours of operation are Monday through Friday from 8:00pm-5:00pm. LPA and licensee inspected day care areas for health and safety hazards. LPA observed that off limit areas were properly barricaded and made inaccessible to the children in care.

Day-care areas: Play room(front living room), Bedroom #1(nap room) and bedroom #2 (art room), bathroom #1, and back yard.
Off-limit areas: Bedroom #3 (upstairs master's), Bedroom #4 (guest room), Kitchen/Dining room, back living room and entertainment room(lounge) located downstairs.

LPA observed day care area to be clean and in good repair with proper temperature and ventilation. Backyard is fenced and properly barricaded. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. There's a fully charged fire extinguisher located in the play room. Per Licensee, there are no weapons/firearms or open bodies of water in the home. Licensee's CPR & First Aid expires on 10/2026. Licensee's Mandated Reporter certificate also expires on 10/2026. LPA observed a pull alarm and smoke/CO detectors are present. Capacity limits of a Small and Large Family Child Care Home were explained and LIC 9149 is on file.

As of today's date, July 22, 2026, the facility is approved for a Large Family Child Care Home with a maximum capacity of 14 children in care.

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.

Exit interview was conducted and report was reviewed by licensee, Anna Kajsa Johnson.
Daniel J Oquendo
Nathan Garcia
DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2026
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
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)
Page: 2 of 2