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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001225
Report Date: 03/10/2025
Date Signed: 03/10/2025 11:21:20 AM

Document Has Been Signed on 03/10/2025 11:21 AM - 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:ORELLANA, SONIA & HERNANDEZ, ADANFACILITY NUMBER:
384001225
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
03/10/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Sonia OrellanaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 3/10/2025 at 8:40AM. Licensing Program Analyst (LPA) Luis Gomez met with licensee, Sonia Orellana. Purpose of this report is to cite for deficiencies observed during facility inspection. Present was the licensee caring for 5 children. (4 preschool-age 1 infant-age) LPA inspected facility for health and safety hazards.

At 8:45AM., Based on observation and interview, LPA confirmed backyard area has been temporarily removed from on-limit areas due to on-going tree removal. Advisory Note: Technical Violation (LIC9102TV) was issued.

At 9:00AM., Based on observation, LPA confirmed several loose items inside infant crib.

Based on today’s inspection, deficiencies were observed in the areas evacuated according to Title 22, Division 12, Chapter 1 of Ca. Code of Regulations and cited on the 809D. An exit interview, appeal rights, and plan of correction was discussed with licensee, Sonia Orellana. A copy of this report with the appeal rights was provided, and signature of this form acknowledges the receipt of these documents.

Report was reviewed and notice of site visit was provided and shall remain posted for 30 days.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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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Document Has Been Signed on 03/10/2025 11:21 AM - It Cannot Be Edited


Created By: Luis Gomez On 03/10/2025 at 10:59 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: ORELLANA, SONIA & HERNANDEZ, ADAN
FACILITY NUMBER: 384001225

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2025
Section Cited
CCR
102425(b)

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102425(b) Infant Safe Sleep: Cribs and play yard shall be free of loose articles or object. This requirement was not met as evidenced by:
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Licensee will remove all items from inside (above and around) infant crib by due date: 3/12/2025. Licensee will ensure cribs has firm mattress and tight-fitting sheet only. Proof of correction will be submitted to the Department via email.
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At 9:00AM., Based on observation, LPA confirmed several loose items inside infant crib. This poses a potential health and safety risk to children in care.
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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.
SUPERVISOR'S NAME:Marie Rodriguez
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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