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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005685
Report Date: 07/01/2026
Date Signed: 07/01/2026 12:49:09 PM

Document Has Been Signed on 07/01/2026 12:49 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:RODRIGUES, ADRIANYFACILITY NUMBER:
214005685
ADMINISTRATOR/
DIRECTOR:		RODRIGUES, ADRIANYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 951-7032
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 12TOTAL ENROLLED CHILDREN: 9CENSUS: 6DATE:
07/01/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Ariany RodriguesTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On July 1, 2026, Licensing Program Analyst (LPA) Van conducted an announced annual inspection and met with Licensee Adriany Rodrigues. The purpose of the inspection was explained, and the licensee granted LPA access to the home. Upon entering, LPA observed children finishing their morning breakfast. The licensee and two assistants supervised five children, consisting of two infants, two preschool-aged children, and one school-aged child. During the inspection, one additional preschool-aged child arrived, bringing the total number of children in care to six, which remained within the licensed capacity.

LPA conducted a walkthrough of the approved childcare areas, which consist of the living room, bathroom, bedroom #1, bedroom #2, the family room (also referred to as living room #2), and the concrete portion of the outdoor yard. The off-limit areas include the kitchen, master bedroom (including the inside bathroom), the gravel area, and all areas beyond the concrete portion of the outdoor yard. These areas were made inaccessible using child safety latches and safety gates. The facility is open Monday through Friday, 7:30 a.m. to 5:30 p.m.

The childcare areas were observed to be clean, organized, and equipped with age-appropriate materials that support learning and development. The home had adequate heating, lighting, and ventilation. The fireplace was properly screened. Safety equipment included a functional carbon monoxide detector, a smoke detector, and a fully charged 2A10BC fire extinguisher. Cleaning supplies and disinfectants were stored out of children’s reach. The licensee confirmed that no firearms or weapons are present in the home. No prohibited items such as baby walkers or bouncers were observed. LPA reminded the licensee that smoking is prohibited in family childcare homes. According to the licensee, there are no pools, spas, or bodies of water on the premises. The licensee also reports that she has a pet dog with all vaccinations up to date.


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NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2026
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 07/01/2026 12:49 PM - It Cannot Be Edited


Created By: Brendon Van On 07/01/2026 at 11:31 AM
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: RODRIGUES, ADRIANY
FACILITY NUMBER: 214005685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2026

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 cited above section of the regulation. The licensee’s mandated reporter training certificate had expired, and the assistant had not completed the mandated reporter training. Required documentation was not available for review at the time of inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2026
Plan of Correction
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The licensee and her assistant will complete the Mandated Reporter Training for Child Care Providers and submit updated certificates to the Department. The licensee will ensure the training is renewed every two years and that both certificates are maintained in the staff files as required. A return visit will be required to verify that the corrections have been completed and that the facility is in compliance.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee’s helper did not have documentation of her Tdap (pertussis) immunization on file or available for review during the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2026
Plan of Correction
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The licensee will obtain and maintain documentation of the helper’s Tdap (pertussis) immunization and place the record in the staff file. The licensee will ensure all required staff immunization records are kept current and available for review. A return visit will be required to verify that the corrections have been completed and that the facility is in compliance.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Garfield Leung
NAME OF LICENSING PROGRAM MANAGER:
Brendon Van
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2026


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: RODRIGUES, ADRIANY
FACILITY NUMBER: 214005685
VISIT DATE: 07/01/2026
NARRATIVE
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LPA observed six play yards present in the child care areas. All play yards were free of toys, blankets, pillows, or other items. Mattresses fit properly, and sheets were tightly secured. The licensee uses the Brightwheel app to maintain children’s records and 15-minute sleep logs. A review of the logs confirmed that entries were completed with dates, included the required 15-minute check intervals, and included each child’s name. LPA reminded the licensee that logs must be available upon request and reiterated that sleep sacks are not permitted in licensed care.

LPA reviewed children’s files. Children’s files contained required documentation, including emergency information, immunization records, and parental rights forms. LPA reminded the licensee to transfer all children's immunization records onto the PM 286 form and ensure they are available for future inspections.

LPA reviewed personnel files and observed the following: the licensee’s mandated reporter training certificate was expired; the assistant had not yet completed the mandated reporter training; and the licensee’s helper did not have documentation of her Tdap (pertussis) immunization on file or available for review during the inspection. These items must be maintained in staff files and made available for review.

During the inspection, LPA reminded the licensee that if her mother is present in the home as a visitor, she may not provide care for children or have contact with children in care. LPA explained that if the licensee’s mother provides care or has contact with child care children, she is considered an assistant and, therefore, must meet all assistant requirements. This includes completing mandated reporter training and maintaining required immunizations such as measles, pertussis (Tdap), and influenza. All documentation must be kept in the staff file and available for review.

All required licensing postings were observed. The licensee reported that fire and earthquake drills are conducted at least every six months, with the most recent drill completed on May 12, 2026.

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: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
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: RODRIGUES, ADRIANY
FACILITY NUMBER: 214005685
VISIT DATE: 07/01/2026
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information, 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 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: www.ada.gov/childqanda.htm

LPA discussed the safe sleep regulations with the Licensees and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the 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 that as of September 1, 2016, a person may not be employed or volunteer at a childcare 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.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

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.

During the exit interview, the LICENSEE, ADRIANY RODRIGUES, confirmed that there are no Registered Sex Offenders living in the facility, and LPA completed the RSO profile in FAS.

See LIC 809D for deficiencies cited today.

A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted, the report and appeal rights were reviewed with the licensee, Adriany Rodrigues.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC809 (FAS) - (06/04)
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