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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004346
Report Date: 03/03/2025
Date Signed: 03/03/2025 04:54:35 PM

Document Has Been Signed on 03/03/2025 04:54 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:ACEVES, ROSAURAFACILITY NUMBER:
384004346
ADMINISTRATOR/
DIRECTOR:		ACEVES, ROSAURAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 424-6628
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
03/03/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Rosaura AcevesTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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On 3/3/2025 at 2:05PM., Licensing Program Analyst (LPA), Luis Gomez met with Licensee, Rosaura Aceves. The purpose of today’s visit was explained and was for an unannounced, annual random inspection. Present was the licensee and two assistants caring for 9 children. (3 infant-age, 6 preschool-age) Adults have criminal record clearances on file. Licensee’s home is a two bedroom, one bathroom, two level house. The days and hours of operations are: Monday- Friday, 8:00AM- 5:00PM. Areas of the home designated for childcare are the: Lower Level: Backyard; Upper Level: Bathroom; Living Room (Playroom #1); and Dining Area (Playroom #2). Areas of the home designated as off-limits are the: Lower Level: Garage; Upper Level: Kitchen (Pass through only); Bedroom #1, #2, LPA inspected facility for health and safety hazards.

At 2:10PM, the following was observed: Facility was had age-appropriate playthings available for the children in care. The floors and ground surfaces were clear of any obstructions. Fireplace has been properly barricaded. Storage cubbies are available in entry way for children’s belongings. LPA observed tables and chairs, scaled to the appropriate size. Accessible furniture, materials, and supplies inspected were in good repair, free of sharp corners or splinters. LPA reminded licensee to cover exposed corner near fireplace. For napping services, LPA observed cots and cribs available.

At 2:25PM., Based on observation, confirmed cribs available without tight-fitting sheet.


At 2:30PM., Based on observation, LPA confirmed staff picking up child as intervention technique during free play.

Bathroom #1 was observed clean and operating condition. Detergents, cleaning compounds, and item which can pose a danger, have been stored inaccessible to children. Lockable doors and child safety gates have been installed preventing access to off-limit areas. Home was a comfortable temperature, with ventilation, and lighting. Home has telephone service; carbon monoxide detector, smoke detector; and fire extinguisher (2A:10BC). (REFER TO 809C, FOR CONT.)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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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Document Has Been Signed on 03/03/2025 04:54 PM - It Cannot Be Edited


Created By: Luis Gomez On 03/03/2025 at 03:35 PM
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: ACEVES, ROSAURA
FACILITY NUMBER: 384004346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 3:00PM., Based on record review, LPA confirmed facility has not conducted emergency disaster drill within last 6 months. This poses a potential health and safety risk to children in care.
POC Due Date: 03/10/2025
Plan of Correction
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Licensee will conduct and log emergency disaster drill by due date: 3/10/2025. Proof of correction will be submitted to Department via email.
Type B
Section Cited
CCR
102425(a)(3)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 2:25PM., Based on observation, confirmed cribs available without tight-fitting sheet. This poses a potential health and safety risk to children in care.
POC Due Date: 03/10/2025
Plan of Correction
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Licensee will ensure tight-fitting sheet is installed by due date: 3/10/2025. Proof of correction will be submitted to Department via email.
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: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/03/2025 04:54 PM - It Cannot Be Edited


Created By: Luis Gomez On 03/03/2025 at 03:35 PM
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: ACEVES, ROSAURA
FACILITY NUMBER: 384004346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 3:10PM., Based on record review, LPA confirmed immunization records missing from children's files. This poses a potential health and safety risk to children in care.
POC Due Date: 03/17/2025
Plan of Correction
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Licensee will ensure children proof of immunization and required forms are stored in facility records by due date: 3/17/2025.
Proof of correction will be submitted to Department via email.
Type B
Section Cited
CCR
102423(a)(1)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (1) To be treated with dignity in his/her personal relationship with staff and other persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 2:30PM., Based on observation, LPA confirmed staff picking up child as intervention technique during free play. This poses a potential health and safety risk to children in care.
POC Due Date: 03/10/2025
Plan of Correction
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Licensee will be provided teaching pyramid to staff for proper behavior intervention techniques in licensing child care.
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: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


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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: ACEVES, ROSAURA
FACILITY NUMBER: 384004346
VISIT DATE: 03/03/2025
NARRATIVE
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(PAGE 2)
At 2:30PM., LPA reviewed the Backyard Area. Padding has been installed on floor surface and sharp corners. Outdoor toys and playthings were in good repair. LPA reminded licensee to remove plants with thorns from backyard area. Home/ building does not have any pools; fishpond; jacuzzi; or other bodies of water.

At 2:45PM., LPA reviewed facility records including children and personnel files. The children’s files were reviewed and included the: Identification and Emergency Information (LIC700); Consent for Medical Treatment (LIC624).

At 3:10PM., Based on record review, LPA confirmed immunization records missing from children's files.

LPA reminded licensee to ensure guardians sign the required LIC9227, Individual Infant Sleeping Plan for qualifying children in care. Advisory Note: Technical Violation (LIC9102TV) was issued.

Personnel files were reviewed and included staff’s: Proof of Immunization.

Licensee’s cardiopulmonary resuscitation (CPR)/ Pediatric First Aid Certification was current, expiring: 2/2026.
LPA reminded licensee to renew mandated reporter training course (AB1207). Advisory Note: Technical Violation (LIC9102TV) was issued.

At 3:00PM., Based on record review and interview, LPA confirmed facility has not conducted emergency disaster drill within the last 6 months.

The required forms are posted in entry and include the: License; Notification of Parent’s Rights (PUB379)
LPA advised licensee to have Written Emergency Disaster Plan (LIC610) available.

Per licensee, isolation of an ill child is in the playroom. Per licensee, facility provides daily snack/ meal services for children in care. LPA observed pet dog in facility. Per licensee pet has required vaccines. (REFER TO 809C, FOR CONT.)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 03/03/2025
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: ACEVES, ROSAURA
FACILITY NUMBER: 384004346
VISIT DATE: 03/03/2025
NARRATIVE
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(PAGE 3)
Licensee was reminded that all adults 18 years and over, living in the home, person who provides care and supervision to children, and staff who have contact with children, including employee and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain criminal 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.

LPA discussed safe sleep regulations with licensee and the Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.



Facility was informed of the www.mychildcareplan.org site is a consumer education website that helps families obtain child care by connecting to child care providers and resources and referral agencies (R&R) throughout California.

Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 20-02-CCP. When an IMS is provided, a plan for 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- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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 tool, please send them 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/inforesource/community-care-licensing/inspection-process.(REFER TO 809C., FOR CONT.)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 03/03/2025
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: ACEVES, ROSAURA
FACILITY NUMBER: 384004346
VISIT DATE: 03/03/2025
NARRATIVE
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(PAGE 4)
Based on today's inspection, deficiencies were cited in areas evaluated according to California Title 22, Div. 12 Chap. 3, Health and Safety Code of Regulations. An exit interview and facility evaluation report was discussed with Licensee, Rosaura Aceves
Licensee’s signature of this form acknowledges the receipt of these documents.

During exit interview, licensee confirmed no registered sex offenders are living in the facility, and LPA completed RSO profile. Notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

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

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