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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005157
Report Date: 03/17/2026
Date Signed: 03/17/2026 04:23:57 PM

Document Has Been Signed on 03/17/2026 04:23 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:RIBEIRO, KARINA M. & BUENROSTRO, MARIA C.FACILITY NUMBER:
214005157
ADMINISTRATOR/
DIRECTOR:		RIBEIRO, KARINA MFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 246-1409
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
03/17/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Maria BuenrostroTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On March 17, 2026, Licensing Program Analyst (LPA) Naves conducted an unannounced required visit to the Family Childcare Home listed above. During today’s visit, the LPA met the Co-Licensee, Maria Buenrostro. During today’s visit, the co-licensee was not present at home. The co-licensee was informed of the reason for today's visit by the LPA. During today's visit, 3 infants and 7 preschool-aged children were present in the home. Present in the home with fingerprint clearance included the co-licensee and the co-licensee’s assistant. The home operates within its capacity and in accordance with the required ratio of staff to children.

LPA provided licensee with LIC 126 Entrance Checklist. Licensees hours of operation are 7:30 am-5:30pm Monday- Friday.

Daycare areas: The playroom, Sleep area, Backyard, Bathroom #1, Bedroom #1, and Bedroom #2 are used for napping only.

Off-limit areas: Kitchen, Bedroom #3, Master bathroom, and Living area. All off-limit areas are secured with a locked door or a safety gate. The co-licensee understands that off-limits areas may not be used for childcare during business hours.

The LPA and the co-licensee conducted an inspection to identify any potential health and safety hazards. The daycare provides toys and equipment for children of the appropriate age range. During the inspection, the LPA observed that the playground equipment and outdoor furnishings appear to be in excellent condition. The outdoor play area has..
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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2026
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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Document Has Been Signed on 03/17/2026 04:23 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 03/17/2026 at 03:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: RIBEIRO, KARINA M. & BUENROSTRO, MARIA C.
FACILITY NUMBER: 214005157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in a disaster drill had not been conductd within the last 6 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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Co-licensee will conduct a disaster drill by 3/27/26 and will email LPA with proof of logged drill.
Type B
Section Cited
CCR
102417(g)(10)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation , the licensee did not comply with the section cited above in a baby walker was present in the play area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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Co-licensee removed baby walker and was advised it cannot be used in daycare.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Jaclyn Naves
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/17/2026 04:23 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 03/17/2026 at 03:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: RIBEIRO, KARINA M. & BUENROSTRO, MARIA C.
FACILITY NUMBER: 214005157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed a nap toy in an infants crib which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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Co-licensee removed item and was reminded infants can not sleep with items in cribs.
Type B
Section Cited
HSC
1596.814(a)(1)(B)(i)(I)
Pool Safety
(i) (I) An approved safety pool cover that is manually or power operated and meets the performance standards of ASTM International Standard F1346-23.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in a pool cover was not present which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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Licensee will get a pool cover that is ASTM International Standard F1346-23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Jaclyn Naves
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/17/2026 04:23 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 03/17/2026 at 03:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: RIBEIRO, KARINA M. & BUENROSTRO, MARIA C.
FACILITY NUMBER: 214005157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(1)(B)(ii)(I)
Pool Safety
(ii) (I) An alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water. The alarm shall be turned on and be in working condition during a facility’s operating hours while the swimming pool is not in use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the pool did not have an alarm in the pool which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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licenseee will get a pool alarm and provide proof to LPA by 4/17/26
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in liccensee was not present but is in Brazil and did not inform CCLD of her absence,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee will review regulations over absences and submit documentation as to what she has reviewed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Jaclyn Naves
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 03/17/2026 04:23 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 03/17/2026 at 03:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: RIBEIRO, KARINA M. & BUENROSTRO, MARIA C.
FACILITY NUMBER: 214005157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in both nap rooms had the doors closed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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licensee will send LPA a statement as to how she will prevent this deficiency from happpening again.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Jaclyn Naves
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2026


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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RIBEIRO, KARINA M. & BUENROSTRO, MARIA C.
FACILITY NUMBER: 214005157
VISIT DATE: 03/17/2026
NARRATIVE
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artificial turf under play equipment. The home has adequate lighting and ventilation and is free of any defects or conditions that may put children at risk. The home has a fully stocked first aid kit available during today's visit. The home has a smoke detector, a carbon monoxide detector, which was not tested due to children napping during visit and a fire extinguisher. All garbage cans and power outlets are appropriately covered. All cleaning and washing products, along with any other harmful materials, are kept out of children's reach. During today's visit, the LPA observed a baby walker which is prohibited to have in the FCCH. According to the co-licensee, no firearms or weapons are on the premises. The LPA observed that the home has a pool. LPA reminded co-licensee of pool safety and went over the requirements for having a pool

The LPA observed two designated areas for children to sleep or rest quietly. The two areas include sleeping mats, sleeping playpens, and blankets for each child. The LPA observed a diaper-changing station in the home, which was clean and safe for the children. Baby wipes and diapers were available for the children in care.

The LPA observed that all required documents, such as the facility license, the Notification of Parental Rights, LPA provided the Earthquake Preparedness Checklist, to display. The facility’s most recent emergency disaster drill, conducted on 6/10/2025, LPA reminded co-licensee drills must be done once every 6 months.

The LPA reviewed the records of both the children and staff members. According to the co-licensee, she doesn't have childcare insurance, which isn't required for a family childcare home. The LPA reviewed the six random children's records and found that all five files contained all necessary documents, Immunization Record, Identification/Emergency Information, Consent for Emergency Medical Treatment, and Notification of Parents’ Rights. The LPA reminded the co-licensee that if a home daycare does not carry childcare insurance, each child’s file must contain the Affidavit Regarding Liability Insurance For Family Child Care Home form. The LPA reviewed the sleeping records of the two children under two and determined that the data was properly recorded. LPA reminded co-licensee sleep logs must be kept and not tossed after the week has concluded. Following a review of the staff records, the LPA found the co-licensee possesses a current certification in Pediatric First Aid/CPR. Ms. Buenrostro’s Pediatric First Aid/CPR certification expires on 1/2028 and Mandated Reporter Certification expires 10/2027.
cont pg 3 >>>>
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RIBEIRO, KARINA M. & BUENROSTRO, MARIA C.
FACILITY NUMBER: 214005157
VISIT DATE: 03/17/2026
NARRATIVE
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The co-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.
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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/.

LPA discussed the safe sleep regulations with the co-licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed the co-licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
The co-licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
During the exit interview, the co-licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
On March 5, 2026, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility
cont pg 4 >>>>
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RIBEIRO, KARINA M. & BUENROSTRO, MARIA C.
FACILITY NUMBER: 214005157
VISIT DATE: 03/17/2026
NARRATIVE
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addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.
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.
See 809D for deficiencies cited today.

The 80/20 attendance expectation was discussed with licensee stated that they understand that they are the primary person responsible for operating and providing care and supervision to the children, regardless if the licensee hires helpers or assistants to work with them. Licensee understands that they may only be absent from the home no more than twenty percent of the operating hours. During the twenty percent absence licensee understands that they may designate another person to provide care and supervision to the children who is qualified with Mandated Reporter Training, Pediatric CPR and First Aid Training, has obtained criminal record clearances, child abuse index checks, a TB test with results, immunizations as required by law, and has a signed Criminal Record Statement and Acknowledgement to Report Suspected Child Abuse forms.
PIN 25-01 pool safety AB 2866 provided to licensee
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.

A copy of today’s report was given to Maria Buenrostro.
Exit interview conducted and report was reviewed with Maria Buenrostro.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
LIC809 (FAS) - (06/04)
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