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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004108
Report Date: 12/03/2025
Date Signed: 12/03/2025 10:51:16 AM

Document Has Been Signed on 12/03/2025 10:51 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:CHEN, DEREKFACILITY NUMBER:
384004108
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
12/03/2025
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:29 AM
MET WITH:Derek ChenTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
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On 12/3/2025, Licensing Program Analysts (LPA), J. Badger, arrived at the above-named location and met with the licensee Derek Chen, to conduct a scheduled case management inspection for a Capacity Increase. The licensee requested a change of capacity from a Small Family Child Care Home to a Large Family Child Care Home. Present in the facility were the licensee, a helper, two infant children and one preschool aged child. While the LPA was completing their inspection, an additional helper arrived. The facility was found to be operating within capacity limits on this day.

All adults living and working in the home are fingerprint cleared and associated, confirmed through a check on the CDSS Guardian Background Check System.

The hours of operation are Monday to Friday, 8:00 am - 5:30 pm.

The Day care area(s) are now: Two large day care rooms, a bathroom and backyard area. The entire lower level of the home, excluding the garage,

Off-limits area(s) are now: The entire top floor of the home.

The licensee has a designated cell phone and understands that it must be kept at home during day care hours. The licensee has reserved a designated space to be used as the isolation area for a sick child. All hazardous materials and toxins are kept out of children's reach and are inaccessible. The applicant licensee to serve all meals and snacks to day care children.

The licensee will provide age-appropriate cots for the children while they are napping.

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2025
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: CHEN, DEREK
FACILITY NUMBER: 384004108
VISIT DATE: 12/03/2025
NARRATIVE
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The licensee is relocating the day care area from the top floor of the home to the ground floor of the home. Child Care Licensing received the fire clearance approval for the capacity increase request on 10/17/2025.

The licensee has installed soft cushioning to the entire floor of the backyard area to prevent injury. There were age-appropriate toys, learning material, ride-on-toys, in the backyard that were in good condition. The backyard area was completely fenced.

Cubbies were available for the children to store their belongings. All electrical outlets were covered and inaccessible to children. The licensee will install child safety gates at the stairway entrance to prevent children access to the off-limit areas.

There was a fully charged 2A10BC fire extinguisher, and working carbon monoxide and smoke detector combination in the main day care area.

According to the applicant, there are no firearms or weapons in the house.

The LPA reminded the applicant that the CPR and First Aid training must be renewed every two years. The applicant has provided evidence that he has received the required immunizations (MMR and TDAP), and he has also proved that he has successfully completed the Mandatory Reporter Training. The LPA reminded the licensee that the Mandated Reporter Training must be renewed every two years.

The LPA informed the licensee that emergency disaster drills should be conducted at least once every six months and that the date and time of the drill should be recorded.

The following is required to be posted in an accessible location in view of parents: Emergency Disaster Plan (LIC 610), Parent's Rights (LIC 995A), and License (once received).

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
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: CHEN, DEREK
FACILITY NUMBER: 384004108
VISIT DATE: 12/03/2025
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Incidental Medical Services (IMS) policy was discussed with the applicant. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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)/ (800) 514-0383 (TTY) and link to the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The licensee was advised that all assistants, volunteers, frequent visitors or adults living in the home, over the age of 18 must be fingerprint cleared, associated to the home and have proof of immunization, prior to having any contact with the children in care. Failure to do so could result in an immediate civil penalty of $100 per person, each day.

The LPA will recommend a Large Family Child Care Home License. The licensee's new license will be effective on 12/3/2025.

The licensee was advised to contact San Bruno Regional Office for concerns or questions. Desk Duty is available Mon-Fri, 8:00am to 5:00pm at (650) 266-8800. Forms and regulations are made available at www.cdss.ca.gov/inforesources/Community-Care-Licensing.

A copy of the report was provided to the licensee

An exit interview was conducted, and the report was reviewed with the licensee, Derek Chen

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
LIC809 (FAS) - (06/04)
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