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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004003
Report Date: 03/25/2025
Date Signed: 03/28/2025 09:10:35 AM

Document Has Been Signed on 03/28/2025 09:10 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:HAMILTON SHELTER PROGRAMFACILITY NUMBER:
384004003
ADMINISTRATOR/
DIRECTOR:		PETROVA, DIANAFACILITY TYPE:
840
ADDRESS:260 GOLDEN GATE AVENUETELEPHONE:
(415) 342-2203
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY: 23TOTAL ENROLLED CHILDREN: 7CENSUS: 0DATE:
03/25/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Diana PetrovaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On March 25, 2025, at approximately 9:00 AM, Licensing Program Analyst (LPA) Zeynep Basak conducted an unannounced annual inspection and met with the HR director, and the director, Diana Petrova arrived at 9:30 AM. The purpose of the visit was explained to the director, and LPA was granted access to the facility. The facility serves school-age children and operates Monday to Friday from 3:00 PM to 6:00 PM.
Upon entry, there were no children present, and the director stated children come between 3 to 6 PM after school. LPA verified the staff members’ background clearance on the Guardian website.

LPA inspected a room and the outdoor play area with the director. LPA observed that the temperature and ventilation levels were appropriately maintained. The facility is equipped with two combo carbon monoxide detectors and smoke alarms, along with a fully charged fire extinguisher (model 2A:10BC) located in the hallway. The facility conducts an emergency drill once a month, with the most recent drill conducted on March 7, 2025.
LPA observed that the facility has age-appropriate furniture, toys, and educational materials in the room. The facility floors are in good condition and free of any hazards.
LPA confirmed that all cleaning solutions and other chemicals are properly stored and made inaccessible to children.
LPA inspected the outdoor play area with the director and confirmed that there is a variety of play and sports equipment available for the children. All play structures are in good repair, and the playground is free from health and safety hazards.
No bodies of water were observed on the premises.

See page 2.
NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Zeynep Basak
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: HAMILTON SHELTER PROGRAM
FACILITY NUMBER: 384004003
VISIT DATE: 03/25/2025
NARRATIVE
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Page 2.
LPA observed that the facility maintains a fully stocked first aid kit and a functioning telephone. Per the director, no child has an allergy and using medication at this time. There is an isolation area at the corner of the room at the facility.

According to the director, the facility provides snacks in addition to drinking water. Per Diana, the facility uses both paper and an electronic sign-in/out app called CMS. Upon review, the record showed that all parents’ signatures matched and accounted for the number of children for the last week.

All posting requirements are met by the facility, including the License, Parent’s Rights, and California Child Passenger Safety Law, as observed by the LPA.

The LPA reviewed the facility records, six children’s files, and two staff files. LPA found all required documents in the children’s files, including LIC 700, and Personal Rights forms. LPA also confirmed that all necessary documents are available in the staff files, including Mandated Reporter Training and LIC 9052.
LPA observed the director has a valid CPR+First Aid certificate which expires on 9/2025 and a Mandated Reporter certificate that expires on 1/2027.

The director was reminded that all adults 18 and over, 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 Child Care Center. 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.
See page 3.
NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Zeynep Basak
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: HAMILTON SHELTER PROGRAM
FACILITY NUMBER: 384004003
VISIT DATE: 03/25/2025
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Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for
drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

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.

No deficiencies were cited today.


An exit interview was conducted, and the report was reviewed with the director, Diana Petrova.

A notice of site visit was given to the director and must remain posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Zeynep Basak
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4