384003034-10-16-2025-05-CC-CQUO-DMHQ2G-20251016114707

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384003034
Report Date: 10/16/2025
Date Signed: 10/16/2025 11:47:20 AM

Document Has Been Signed on 10/16/2025 11:47 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:	SAN AGUSTIN, MICHELLE E.		FACILITY NUMBER:	384003034
ADMINISTRATOR/ DIRECTOR:	SAN AGUSTIN, MICHELLE E.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 488-3931
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94131
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 12	CENSUS: 12	DATE:	10/16/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Michelle San Agustin		TIME VISIT/ INSPECTION COMPLETED:	12:00 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 October 16, 2025 at approximately 9:00am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee, Michelle San Agustin, and explained the purpose of the visit. Present during LPA's visit included licensee, 2 teaching assistants and 12 preschool age children. Licensee is a large license and is operating within capacity limits and ratio during LPA's visit. Licensee lives in the multi-level home with their spouse and minor child. All adults living in the home and working staff have fingerprint clearance on file. Licensee's hours of operations are Monday through Friday 8:30am to 3:30pm. The home consists of 3 levels. Licensee's operates their Montessori family child care home program on the ground level of the home only. Main entrance to the family child care home is through the ground level door. The DAY CARE AREAS are on the ground level of the home only which includes a large classroom, multi-purpose room (napping and gym room), bathroom #1 and backyard area. The OFF LIMIT AREAS are the garage (ground level), ground level kitchen (pass by only) and entire second and third levels of the home. Off limit areas are made inaccessible with child safety gates and a child safety door handle. LPA inspected day care areas for health and safety hazards. There are stairs inside the home that lead to the second and third level of the home that are made inaccessible with a closed door. LPA observed door handle to be high, inaccessible to children. Home is equipped with a variety of Montessori materials. LPA observed children's materials are for language, art, sensorial and practical life skills. Materials are organized, labeled and age appropriate. There is furniture for children's use that are in good condition and also age appropriate. Flooring in day care area is clean. There are rugs that were observed to be clean, free of stains. LPA observed electrical outlets to be made inaccessible to children with child safety covers. (Continue Report on Page 2...)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

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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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: SAN AGUSTIN, MICHELLE E.	FACILITY NUMBER: 384003034
	VISIT DATE: 10/16/2025

NARRATIVE

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There are high cabinets in the day care areas that are labeled with children's materials. There is an area for children's personal belongings that are labeled with their individual names. Home is equipped with multiple smoke and carbon monoxide detectors, multiple fire extinguishers and an emergency backpack.

Bathroom for children's use was observed to be in working condition, equipped with age appropriate toileting equipment. There is a high cabinet in the bathroom, equipped with cleaning solutions and poisons, inaccessible to children. Children utilize reusable hand towels that are labeled with their individual names and sanitized weekly or as per needed.

Licensee provides a food service that includes morning snack, lunch, and afternoon snack. Reusable materials and dishes are utilized and sanitized through home's dishwasher. LPA observed garbage bins with tight fitting lids throughout home. Per licensee, no children currently enrolled have allergies. Per licensee, if a child had an allergy, medication would be stored on site, inaccessible to children.

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/.

Children sleep in the napping/gym room on cots. Sheets are provided by children's families. Per licensee, sheets and blankets are sent home weekly for laundering. LPA did not observe any cribs or play yards on site. Per licensee, the youngest age they will accept is 2 years and 8 months old.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

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: SAN AGUSTIN, MICHELLE E.	FACILITY NUMBER: 384003034
	VISIT DATE: 10/16/2025

NARRATIVE

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Backyard is fully enclosed and fenced. There are stairs in the backyard that lead to off limit areas of home, made inaccessible with child safety gates. Children utilize outdoor shoes when in the backyard. There are a variety of outdoor toys and materials. Per licensee, toys and materials are sanitized every other day. LPA observed backyard to have sufficient shade. LPA did not observe any pools, spas or bodies of water on site.

LPA reviewed facility records that included 6 random, enrolled children's records. Children's records are complete with emergency information and immunization records. Licensee maintains a childcare roster that was made available for LPA's review.

LPA also reviewed licensee and both teaching assistants' records. Licensee's CPR and First Aid certification has expired as of 11/2024, however, is scheduled to renew their certificate 10/18/2025. Proof of renewal was provided to LPA during visit. LPA reminded licensee CPR and First Aid certification must be current for licensee and available for review. A type B citation was issued. There is at least one teaching assistant present with a current CPR and First Aid certification during LPA's visit.

Licensee and teaching assistants present have their required immunizations, available for review during LPA's visit. LPA observed licensee and one teaching assistant's Mandated Reporter certificates have expired as of 11/2024. LPA reminded licensee all teaching staff present, including licensee, must have a current Mandated Reporter certificate that must be renewed every two years. A type B citation was issued.

Licensing documents are posted, made available for review. Disaster drills are conducted and documented, made available for review. During LPA's visit, LPA observed an emergency disaster drill being conducted with enrolled children. There are pets in the home that are located in off limit areas, separate from children in care. Per licensee, there are no weapons or firearms in the home.

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.

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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

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: SAN AGUSTIN, MICHELLE E.	FACILITY NUMBER: 384003034
	VISIT DATE: 10/16/2025

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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.

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

Licensee was issued a Type B citation for expired CPR and First Aid certification. Licensee was also issued a Type B citation for licensee and teaching assistant's expired Mandated Reporter certifications. A plan of correction was discussed. Appeal Rights were provided.

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

Exit interview conducted and report was reviewed with the licensee, Michelle San Agustin.

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Catrina Quimbo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/16/2025 11:47 AM - It Cannot Be Edited

Created By: Catrina Quimbo On 10/16/2025 at 10:57 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: SAN AGUSTIN, MICHELLE E.	FACILITY NUMBER: 384003034
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/16/2025

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
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee and a teaching assistant's (present and working with children during LPA's visit), Mandated Reporter certificates expired as of 11/2024, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2025
	Plan of Correction
1 2 3 4	Licensee stated they and teaching assistant will renew their Mandated Reporter certificates. LPA reminded licensee Mandated Reporter must be AB1207. Proof of completed certificates will be provided to LPA by POC due date.

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee's CPR and First Aid certification has expired as of 11/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2025
	Plan of Correction
1 2 3 4	Licensee provided LPA proof they are scheduled to renew their certification 10/18/2025 during LPA's visit. LPA reminded licensee that are have to have a current CPR and First Aid certificate at all times. LPA also reminded licensee certificate must be EMSA certified. Proof of completed certificate will be provided to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:

	Catrina Quimbo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

LIC809 (FAS) - (06/04)

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