214005708-4-30-2026-05-CC-NTRN-DTN2MS-20260430173137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214005708
Report Date: 04/30/2026
Date Signed: 04/30/2026 05:31:53 PM

Document Has Been Signed on 04/30/2026 05:31 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:	NICOLAS, JOSEPHINE		FACILITY NUMBER:	214005708
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 7	DATE:	04/30/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:30 PM
MET WITH:	Licensee, Josephine Nicolas		TIME VISIT/ INSPECTION COMPLETED:	05:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On April 30, 2026, at approximately 2:40PM, Licensing Program Analyst (LPA) Nicole Tran conducted an unannounced, annual inspection. LPA met with licensee, Josephine Nicolas, and explained the purpose of the inspection. Present during LPA’s visit included licensee, one assistant, and seven children (1 infant, 4 preschool age children, and 2 school age children). Licensee is a small license and is operating within capacity limits and ratio during LPA’s visit. Hours of operation are Monday to Friday from 6:00AM to 5:30PM. Licensee lives in a single-family home with their spouse and two minor children. All adults living in the home and staff present have fingerprint clearance on file. Daycare Areas: Bedroom #1 (main daycare area), Dining Room, Living Room, Kitchen, Backyard, and Bathroom #1. Off-limits Areas: Bedroom #2, Bedroom #3, and Garage (room connected to the Kitchen). Off-limit areas are made inaccessible with child safety covers, gates, and latches. With licensee, LPA inspected the facility for health and safety hazards. LPA observed home to be in good condition and free of debris. Home is equipped with a fully charged 3A40BC fire extinguisher, a fully stocked first aid kit, and a smoke and carbon monoxide detector. There is a manual fire alarm pull by the front entrance. Poisons, chemicals, and cleaning detergents have been made inaccessible. Per licensee, there are no weapons or firearms in the home. Continued on Page Two

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

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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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: NICOLAS, JOSEPHINE	FACILITY NUMBER: 214005708
	VISIT DATE: 04/30/2026

NARRATIVE

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LPA observed electrical outlets to be made inaccessible with child safety covers. Flooring in the home includes soft padding that is clean and in good condition. LPA observed the home to have a variety of toys and equipment that are age appropriate. Children have access to toys, manipulatives, and dramatic play materials. There are also areas for rest and relaxation. Licensee provides a full food service that includes breakfast, lunch, and snacks. Per licensee, there are no enrolled children with allergies.

Drinking water is available from a filtered water pitcher. Children drink water from cups provided by licensee.

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/.

Bathroom for children’s use was observed to be in working condition and is equipped with age-appropriate toileting equipment. LPA observed the cabinet in bathroom to have a child safety lock installed. Per licensee, they provide diapers and wipes for infants. There are multiple garbage bins with tight fitting lids in the home to dispose of dirty diapers.

Children sleep on mats and pack and plays. Licensee provides sheets for cots while children's families bring personal blankets for cots. Per licensee, linens are laundered by them daily. Licensee maintains sleeping logs for napping infants. LPA observed the sleep log to only contain the start and end time of the nap. LPA advised licensee that a sleep check must be documented every 15 minutes for infants.

LPA discussed the safe sleep regulations with 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 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.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

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: NICOLAS, JOSEPHINE	FACILITY NUMBER: 214005708
	VISIT DATE: 04/30/2026

NARRATIVE

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Backyard is fully enclosed and fenced. There is sufficient shade from trees and structures for children to rest under. There are a variety of outdoor toys and materials that are age appropriate. Tricycles, trucks, and a sandbox are available for children’s use. LPA did not observe any pools, spas or bodies of water on site.

Licensing documentation is properly posted and made available for review by the front entrance. A childcare roster was also made available for LPA's review. Emergency disaster drills are conducted and are appropriately documented. The last disaster drill was conducted on March 17, 2026. Licensee's Mandated Reporter certification is current and will expire February 2027. Licensee's pediatric CPR/First Aid is also current and will expire September 2027. Licensee has required immunizations on file. Licensee has current childcare liability insurance.

LPA reviewed all enrolled children's records and found them to contain the notification of parents’s rights form. LPA reviewed the assistant’s file and found them to have criminal record clearance and the employee rights form. Assistant’s immunization records and mandated reporter training were not available for review.

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.

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.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

LIC809 (FAS) - (06/04)

Page: 6 of 7

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: NICOLAS, JOSEPHINE	FACILITY NUMBER: 214005708
	VISIT DATE: 04/30/2026

NARRATIVE

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

No deficiencies were issued today during LPA's visit. Appeal rights were provided to licensee.

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

Exit interview conducted and report was reviewed with the licensee, Josephine Nicolas.

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Nicole Tran
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

LIC809 (FAS) - (06/04)

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