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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005622
Report Date: 12/20/2024
Date Signed: 12/20/2024 04:08:34 PM

Document Has Been Signed on 12/20/2024 04:08 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ARGUEDAS PASARA, PAMELAFACILITY NUMBER:
214005622
ADMINISTRATOR/
DIRECTOR:		ARGUEDAS PASARA, PAMELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 209-8155
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
12/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Pamela ArguedasTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On December 20, 2024, Licensing Program Analyst (LPA) Nathan Garcia conducted a subsequent complaint inspection in response to a complaint received by the department on 10/4/24. LPA met with Licensee, Pamela Arguedas and explained purpose of inspection. Present during the visit are 4 infant children in care, including the Licensee's granddaughter with the Licensee and her adult daughter, son, and husband.

During the course of the complaint investigation, LPA determined that the Licensee has thrown away the documents of the 2 previously enrolled children which is not compliant with record keeping regulations that needs to be kept for 3 years. During today's visit, LPA also observed that the facility had an exersaucer in the day care area. According to Licensee, it was given by one of the parents to be used for their children. LPA advised/reminded the Licensee that any bouncers, exersaucers, or bouncers are prohibited.
Although the licensee reported the incident that occurred in the facility on 10/7/2024 by leaving a voicemail for the LPA. The licensee failed to submit a written report of the incident on a LIC624B, making her non-compliant with reporting requirements regulations.

See 809D page for deficiencies cited during today's visit.

Exit interview was conducted with Licensee, Pamela Arguedas.
Report and Notice of Site Visit was provided.
Notice of Site Visit will be posted for 30 days.
Daniel J OquendoTELEPHONE: (650) 379-9023
Nathan GarciaTELEPHONE: (650) 266-8800
DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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 12/20/2024 04:08 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ARGUEDAS PASARA, PAMELA
FACILITY NUMBER: 214005622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
102421 Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
(1) The licensee shall keep the signed and dated notice form for at least three years following termination of service to the child.

This requirement is not met as evidence by:
Deficient Practice Statement
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POC Due Date: 01/20/2025
Plan of Correction
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LPA and Licensee dicussed that rosters and other documents from previously enrolled children will be kept for three years. The licensee states that she has a bin folder with previously enrolled children and will send a verification to LPA by set due date.
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.
Daniel J OquendoTELEPHONE: (650) 379-9023
Nathan GarciaTELEPHONE: (650) 266-8800

DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024

LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/20/2024 04:08 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ARGUEDAS PASARA, PAMELA
FACILITY NUMBER: 214005622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
102416.2 Reporting Requirements
(e) The written report shall be either Form LIC 624B (8/06) Unusual Incident/Injury report-Family Child Care Home, or a letter that includes the following information, in addition to that required by Health and Safety Code Sections 1597.467(b)(2)(A) through (b)(2)(D):
(5) Description of how the incident or injury happened and name of the child(ren) or adult(s) that may have been involved as well as any steps taken to prevent the incident or injury from recurring.

This requirement is not met as evidence by:
Deficient Practice Statement
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POC Due Date: 01/20/2025
Plan of Correction
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The licensee will submit the unusual incident report to the department/LPA by the set due date.
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.
Daniel J OquendoTELEPHONE: (650) 379-9023
Nathan GarciaTELEPHONE: (650) 266-8800

DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024

LIC809 (FAS) - (06/04)
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