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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004808
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:50:27 PM

Document Has Been Signed on 12/21/2023 03:50 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:MARTINEZ SEGOVIA, ANDRESFACILITY NUMBER:
384004808
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Andres Segovia MartinezTIME COMPLETED:
03:55 PM
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On 12/21/2023 at 1:20PM., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Andres Segovia Martinez. Purpose of inspection was explained and was for an Announced; Prelicensing inspection for change of location. Present in home was the licensee and no children. Licensee's home is a 4 bedroom, 3 bathroom, 1 level unit. Days and hours of operations are: Monday- Friday, 8:00AM.- 5:00PM. Daycare Areas are: Bedroom #1 (Playroom #1), Bedroom #2 (Napping Only), Bathroom #1, Bathroom #2, Kitchen, Living Room (Lunch Area/ Playroom #2). Off-limit Areas are: Bathroom #3; Bedroom #3, Bedroom #4, and Backyard. LPA inspected home with licensee for health and safety hazards.

At 1:30PM., the following was observed: Home was clean, orderly, with age-appropriate playthings. Furniture, toys and books inspected were in good repair. LPA observed cubbies for children’s belongings. Playroom #2 has child sized tables and chairs for seated activities. Bathroom #1 and Bathroom #2, were clean, with adequate supplies for hand washing. For napping services, Licensee has several cribs stored in bedroom #2. Cribs inspected were equipped with tight fitting sheets, and properly sized mattresses. The off-limit areas have been made inaccessible. Home had a comfortable temperature, with adequate ventilation and lighting. The detergents; toxins; cleaning compounds; and other items (which could pose a danger) are stored in an off-limit area. Home has a cell phone, functioning smoke/ carbon monoxide combination detector, and a fire extinguisher (3A40BC). Home does not have any pools, jacuzzi, fishponds, or other bodies of water.

At 2:05PM., LPA reviewed with licensee, the LIC311D, Records to Keep in Your Family Child Care Home, Children's Forms/ Records; Facility Forms/Records; and Information to be Posted. (REFER TO 809C, FOR CONT.)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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 3
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: MARTINEZ SEGOVIA, ANDRES
FACILITY NUMBER: 384004808
VISIT DATE: 12/21/2023
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(PAGE 2)
Licensee’s Cardiopulmonary Resuscitation / First Aid certification was current, expiring: 05/21/2024.
Licensee’s Mandated Reporter Training Certification (AB1207) was current, expiring: 06/21/2024.

Per licensee, families will provide food services for families. Isolation of an ill child will be in the hallway. Per licensee, home does not have any firearms or weapons.

Licensee was informed that the Department must be notified prior to the use of designated off-limits areas. LPA and the licensee discussed licensing regulations and the capacity requirements. Any children under 10 years of age will be counted in the capacity. Licensee advised that all food containers brought from home must be properly stored and labeled. Licensee understands the required emergency disaster drills are to be conducted and documented every six months. Licensee understands that the use baby walkers, bouncers, jumpers and similar items are not to be used for children in care. Smoking is prohibited inside of a Family Childcare Home.

Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility, unless he or she has been immunized for influenza, pertussis and measles or qualifies for an exemption pursuant to Health and Safety Code 1596.7995 and 1597.662.

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 and Licensee discussed the safe sleep regulations with licensee and discussed 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.
(REFER TO 809C, FOR CONT.)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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: MARTINEZ SEGOVIA, ANDRES
FACILITY NUMBER: 384004808
VISIT DATE: 12/21/2023
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On 12/21/2023, the California Attorney General – Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California’s Megan’s Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not be included in this search. However, the department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses, pursuant to information shared by California DOJ.

Licensee were informed of the Mychildcareplan.org site, a consumer education website that helps families obtain childcare by connecting to childcare 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

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important communication platform.


To receive important licensed- related information to licensed facilities, visit the CCLD important information website at https://www.cdss.ca.gov/infosource/community-care-licensing/subscribe and select the child care option to receive email communication.

Prior to recommendation for change of location, licensee must complete the following:
Install safe lock on windows (3) in Bedroom #1
Anchor tall standing furniture piece (cubbies) in Bedroom #1
Finish process of moving into the property
Further department review of application
Submit required form LIC9151

Exit interview was conducted and report was reviewed with Licensee, Andres Segovia Martinez. This report will be kept in facility file and made available for public review upon request. Desk Duty is available Monday- Friday between 8AM - 5PM at (650) 266 -8800.

LPA unable to print report during inspection. Copy of report will be sent to licensee at a later date.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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