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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005383
Report Date: 07/28/2026
Date Signed: 07/28/2026 01:57:10 PM

Document Has Been Signed on 07/28/2026 01:57 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:DUQUE, KARINA & GALEANA, VICENTEFACILITY NUMBER:
214005383
ADMINISTRATOR/
DIRECTOR:		DUQUE, K. & GALEANA, V.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 686-7328
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 9DATE:
07/28/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Karina DuqueTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On July 28, 2026 Licensing Program Analyst (LPA) Naves conducted an unannounced annual visit to the Family Childcare Home (FCCH) listed above. LPA met with the Licensee, Karina Duque, and explained the purpose of the visit and was granted entry to the home. Present in the home today was licensee, co licensee and 2 helpers supervising 9 children (5 preschool-aged children, and four infants). The licensee, and co-licensee the licensee's assistants, present at the FCCH have all received criminal record clearance from the department. The FCCH operates within its capacity and in accordance with the required ratio of staff to children. At around 11:00am co-licensee (licensees husband left)

LPA observed that all required documents, such as the facility license, the Notification of Parental Rights, were displayed in the FCCH. LPA did not see the Earthquake Preparedness Checklist posted ,LPA provided licensee with form . LPA provided licensee with LIC 126 Entrance Checklist for items to be reviewed during todays visit. LPA observed that the last emergency disaster drill was conducted on 3/10/2025 and properly recorded. LPA reminded licensee disaster drills must be conducted every 6 months. A deficiency was cited today.

Licensees hours of operation are Monday- Friday 8:00am -5:30pm.

Licensee provides breakfast lunch and snacks for the children. LPA reminded the licensee about the importance of sanitation and proper food preparation.

cont pg 2 >>>>

Ali Zebila
Jaclyn Naves
DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2026
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 11
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 11
Document Has Been Signed on 07/28/2026 01:57 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 07/28/2026 at 12:12 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: DUQUE, KARINA & GALEANA, VICENTE
FACILITY NUMBER: 214005383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

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 licensee had not documented a disaster drill since 3/10/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2026
Plan of Correction
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Licensee will conduct a drill and document it by 8/31/2026. A follow up visit will be required to clear all deficiencies.

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: 07/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2026


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 07/28/2026 01:57 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 07/28/2026 at 12:12 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: DUQUE, KARINA & GALEANA, VICENTE
FACILITY NUMBER: 214005383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 2 out of 4 staff members did not have current certifications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2026
Plan of Correction
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Licensee will ensure all staff has completed Mandated Reporter training by 8/31/2026. A follow up visit will be required to clear all deficiencies.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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 0 out of 4 staff members did not have current available certifications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2026
Plan of Correction
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Licensee ensure herself and licensee have current first Aid CPR certificaions by 8/31/2026. A follow up visit will be required to clear all deficiencies.
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: 07/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2026


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 07/28/2026 01:57 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 07/28/2026 at 12:12 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: DUQUE, KARINA & GALEANA, VICENTE
FACILITY NUMBER: 214005383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

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 0 out of 4 staff records were incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2026
Plan of Correction
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Licensee will ensure all staff members have complete records by 8/31/2026. A follow up visit will be required to clear all deficiencies.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

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 4 out of 9 childrens records were incomplete and did not have immunization records present which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2026
Plan of Correction
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Licensee will ensure all children have immunization records by 8/31/2026. A follow up visit will be required to clear all deficiencies.
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: 07/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2026


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 07/28/2026 01:57 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 07/28/2026 at 12:12 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: DUQUE, KARINA & GALEANA, VICENTE
FACILITY NUMBER: 214005383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

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 4 out of 9 records were missing required forms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2026
Plan of Correction
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Licensee will ensure all children have required forms and complete records by 8/31/2026. A follow up visit will be required to clear all deficiencies.
Type B
Section Cited
CCR
102425(d)(1)
Infant Safe Sleep
The provider shall place infants up to 12 months of age on their backs for sleeping. This requirement shall not apply if the infant has a medical exemption from a licensed physician that allows for an alternative sleep position. The exemption shall be attached to the Individual Infant Sleeping Plan [LIC 9227 (3/20)] and contain the following criteria:

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 0 out of 4 infants did not have LIC 9227 Individual infant sleeping plans which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2026
Plan of Correction
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Licensee will ensure all infants under 12 months have lic 9227 by 8/31/2026. A follow up visit will be required to clear all deficiencies.
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: 07/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2026


LIC809 (FAS) - (06/04)
Page: 6 of 11
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: DUQUE, KARINA & GALEANA, VICENTE
FACILITY NUMBER: 214005383
VISIT DATE: 07/28/2026
NARRATIVE
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Day-care Areas: Living room (main activity room), a bedroom (converted into a playroom downstairs), bathroom in the lower level. Backyard gated deck.

Off-limit Areas: Kitchen, the upstairs bedrooms, garage/workshop downstairs, applicant's bedroom, and the left side alley. All off-limit areas are secured with a locked door or a safety gate. The licensees understands that off-limits areas may not be used for childcare during business hours.

LPA and the licensee conducted an inspection to identify potential health and safety hazards. LPA observed that the indoor daycare areas were clean and orderly. The FCCH is well-lit, ventilated, and free of hazards that could endanger children. The FCCH is equipped with a fully stocked first aid kit, functioning smoke and carbon monoxide detectors which were tested, and a fully charged fire extinguisher.

LPA observed that the indoor daycare areas were equipped with age-appropriate toys, furniture, and educational materials. LPA observed that no equipment, such as walkers, bouncers, or similar objects, was present in the FCCH. LPA observed that the stairs inside the FCCH were properly secured with a safety gate. LPA observed that each child has an individual permanent or portable storage space for his/her clothing and personal belongings at the FCCH. LPA observed that feeding chairs were available in the FCCH.

LPA observed that poisons, cleaning solutions, and chemicals were stored on high shelves or shelves with child safety locks to make them inaccessible to children.

LPA observed bathrooms to be clean and in working condition. Bathroom garbage bins were observed to have tight-fitting lids. LPA observed that the toilets and handwashing facilities at the FCCH were operating safely and in sanitary condition.

cont pg 3 >>>>

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC809 (FAS) - (06/04)
Page: 9 of 11
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: DUQUE, KARINA & GALEANA, VICENTE
FACILITY NUMBER: 214005383
VISIT DATE: 07/28/2026
NARRATIVE
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page 3
According to licensee, no firearms or weapons are on the premises. LPA observed that the entire backyard is fully enclosed and fenced, and the playground equipment and outdoor furniture were in good condition. LPA observed a handwashing sink. LPA observed that the FCCH has no pools, spas, or other bodies of water.

LPA observed that the FCCH has a specific sleeping/resting area for children and a clean diaper-changing station, complete with wipes and diapers. LPA observed that the FCCH provides mats and blankets for children in their care and washes them every 3 days or as needed.

LPA reviewed all 9 children’s files and confirmed that only 4 out of 9 childrens records have complete files that include their emergency contact and medical information. LPA reminded Licensee the importance of having complete files for all children in care ready for review. A deficiency was cited. The licensee was reminded of maintaining accurate and complete sleep logs for all infants under 2 years of age.

LPA reviewed the two licensee’s files and confirmed that only current Mandated Reporter certifications were present. LPA reminded immunizations Current first Aid CPR certifications are required for both licensees as well as LIC 9108 Acknowledgment to report child abuse forms required

LPA reviewed the 2 other staff records and reminded that the Mandated Reporter training certificate for all staff members, all staff TB skin test and immunization record must be submitted to the department as soon as possible as well as LIC 9108 and Lic 9052 Employee Rights form. A deficiency will be cited during todays visit.

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/.

cont pg 4 >>>>

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC809 (FAS) - (06/04)
Page: 10 of 11
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: DUQUE, KARINA & GALEANA, VICENTE
FACILITY NUMBER: 214005383
VISIT DATE: 07/28/2026
NARRATIVE
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page 4

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed 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.

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 licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

On this date, 7/22/2026, 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 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.

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

A Notice of Site Visit was given and must remain posted for 30 days failure to do so may result in a $100 civil assessment.

See LIC 809D for deficiencies cited during today's inspection.

LPA reminded licensee of her past due licensing fees and it needing to be current and up to date immediately. LPA provided Licensee with PIN number and information to pay.

LPA reviewed 80/20 attendance expectation with licensee and reminded Co-licensee must be present as well as he is a co-licensee of facility.

Exit interview conducted and report was reviewed with the Licensee, Karina Duque.

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC809 (FAS) - (06/04)
Page: 11 of 11