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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005677
Report Date: 05/28/2025
Date Signed: 05/28/2025 01:37:22 PM

Document Has Been Signed on 05/28/2025 01:37 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:VALDIVIA, ELIZABETHFACILITY NUMBER:
214005677
ADMINISTRATOR/
DIRECTOR:		VALDIVIA, ELIZABETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 755-7392
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 15DATE:
05/28/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Elizabeth ValdiviaTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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On May 28, 2025, Licensing Program Analyst (LPA) Naves arrived to the facility for an unannounced Annual Inspection and met with the Licensee, Elizabeth Valdivia. The purpose of the inspection was explained. Present in the home were 15 children, 12 pre-school aged and 3 infants, 2 helpers 1 of which is her husband and licensee.

All adults present in the home today have verified criminal record clearance by the department verified through guardian. The hours of operation are Monday through Sunday, 4:00 AM - 11:00 PM. Licensee provides breakfast, AM snacks, Lunch, PM snacks, which are all prepped and served at the facility. Licensee has a current Pediatric First Aid CPR certification valid until 8/2026 and Mandated Reporter training current until 12/2026.

Daycare areas: Indoor play area, Dining Area, Bedroom # 1 (napping only), Laundry area (diaper changing only), Bathroom #2, and the Outdoor play area
Off-limits areas: Bedrooms # 2, 3, and 4 Kitchen, Bathroom # 1 All off-limit areas were equipped with child safety locks or safety gate. .

The LPA and licensee conducted an inspection to identify any potential health and safety hazards. The LPA observed that a fence surrounds the backyard and has age-appropriate play equipment for children to use. The LPA observed artificial grass covering the entire back yard to absorb a child’s fall. The LPA found the play equipment in the backyard is both safe and age-appropriate for children. Licensee has a variety of play houses, swings and slides.The back yard is covered providing adequate shade.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2025
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 05/28/2025 01:37 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 05/28/2025 at 12:36 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: VALDIVIA, ELIZABETH
FACILITY NUMBER: 214005677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

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 15 out of 14 maximum children 2 which must have proof of enrollment of attending school which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2025
Plan of Correction
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The Licensee must comply with her licensed limitations and requirements. She must reduce her capacity and provide Licensing with a written plan and children's schedule to meet her license limitations by May 29, 2025. A written plan and schedule will be submitted to LPA.
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: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


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: VALDIVIA, ELIZABETH
FACILITY NUMBER: 214005677
VISIT DATE: 05/28/2025
NARRATIVE
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The LPA confirmed the presence of fully operational smoke and carbon monoxide detectors in the home. The licensees home has a 2A10BC fire extinguisher and a fully stocked first aid kit. The LPA found the toys, equipment, and learning materials inside the home to be safe and age-appropriate for children.

The LPA observed sleeping playpens and sleeping mats in the designated napping area. The LPA observed that a step stool was present in the designated bathroom for the children, and power outlets were properly covered with child safety covers. The LPA observed that safety covers were present on the kitchen stove knobs. The LPA observed that all hazardous materials and toxins were inaccessible to children by keeping them in cabinets with child safety locks. The home has one washing machine and dryer secured with child safety locks. The home has a diaper changing station in the laundry area, which appears clean and safe for the children to use.

The licensee has a small dog which is vaccinated and has their own designated area.

All required forms are posted in facility, including the Facility License; Notification of Parent’s Rights (PUB379); and Emergency Disaster Plan (LIC610A).
The 80/20 attendance expectation was discussed with licensee and understood.


The licensee confirmed that there were no firearms or weapons in the home. The licensee also identified the dining area as the isolation area for a sick child. The LPA observed that no baby walkers, bouncers, jumpers, and other similar equipment were present in the home today.The LPA reviewed the emergency disaster drills log which was properly logged and conducted at least once every six months. Licensee provided sleep logs for all infants in care under 24 months.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
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: VALDIVIA, ELIZABETH
FACILITY NUMBER: 214005677
VISIT DATE: 05/28/2025
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information 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: on see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the www.ada.gov/childqanda.htm.

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.



LPA reviewed AB 1207 with the Licensees. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. Effective July 1, 2020, Licensees must have proof of completion of EMSA certified lead poison training if applying for a change of location or capacity change to an existing license.

LPA encouraged the Licensee to visit the Licensing website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.



LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at:

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

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: VALDIVIA, ELIZABETH
FACILITY NUMBER: 214005677
VISIT DATE: 05/28/2025
NARRATIVE
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https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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.



On this day licensee is operating over her capacity limitations which poses a health and safety risk to children in care. LPA discussed care and supervision with the Licensee. Capacity options were reviewed, and the Licensee acknowledges that care cannot be provided over the capacity specified on the license.

Based on today's inspection, deficiencies were cited in areas evaluated according to California Title 22, Div. 12 Chap. 3, Health and Safety, Code of Regulations and cited on 809D. Exit interview, Plans for correction, and Facility Evaluation Report was reviewed with Licensee, Elizabeth Valdivia, Licensee’s signature of this form acknowledges the receipt of these documents.

LPA Naves informed the Licensee Elizabeth Valdivia that this report dated May 28, 2025, document(s) a Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA informed the licensee to provide a copy of this licensing report dated May 28, 2025, that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

During exit interview, licensee, Elizabeth Valdivia confirmed that there are no registered sex offenders living in the facility, and LPA completed the RSO profile. Notice of site visit was given and must remain posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
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