384004808-3-21-2025-05-CC-MZAA-DEYTXB-20250321150651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004808
Report Date: 03/21/2025
Date Signed: 03/21/2025 03:07:02 PM

Document Has Been Signed on 03/21/2025 03:07 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, ANDRES		FACILITY NUMBER:	384004808
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 5	DATE:	03/21/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Licensee, Andres Martinez Segovia		TIME VISIT/ INSPECTION COMPLETED:	03:30 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 March 21, 2025, at approximately 12:45pm, Licensing Program Analyst (LPA) Melissa Zaragoza conducted an unannounced, annual inspection. LPA was greeted and granted access by the staff assistant, Irma Gutierrez. At the entrance the staff assistant was explained the purpose of the inspection. Later, during the inspection, at around 1:15pm, the licensee, Andres Martinez Segovia arrived at the facility. Present during LPA's visit included the licensees, 2 staff assistants, and 5 children (2 infants and 3 preschool age children). Hours of operation are Monday through Friday, 7:30am to 4:30pm. Licensee lives in the home with their son. All adults living in the home and staff present have background fingerprint check clearance on file. The DAY CARE AREAS are the kitchen, living room, bathroom #1, bedroom #1, bedroom #2. The OFF-LIMIT AREAS of the home are bathroom #2, bathroom #3, and bedroom #3. All off-limit areas are made inaccessible to children in care with child safety gates. LPA toured day care areas of home with the licensee. LPA observed home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in good condition. LPA observed electrical outlets to be made inaccessible with child safety covers. Cleaning supplies, poisons and hazardous materials are stored in homes high shelves. Home is equipped with a fully charged fire extinguisher and a smoke and carbon monoxide detector. Smoke and carbon monoxide detectors were tested during visit and were observed to be in working condition. LPA observed cubbies with children’s individual names on it. There are no pools, and bodies of water in the premises. Napping area was observed to be equipped with mats and cribs for napping children. Cribs were observed to be loose of any free articles. Children were observed to have their own mats. Per licensee, they provide the sheets and blankets to children in care. Per licensee, sheets and blankets are washed weekly. (Continue Report on Page 2...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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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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: 03/21/2025

NARRATIVE

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Bathroom was observed to be in proper working condition. LPA also observed 1 changing table, used for diapering children. There is appropriate sanitation and toileting equipment for children in care. Per licensee, children’s families provide diapers and wipes for enrolled children. Per licensee, isolation area for when a child is feeling sick, is in bed room #1 (daycare room).

Children eat in the living room. LPA observed the facility to have appropriate eating utensils and highchairs for children to use. Per licensee, they provide a food service of snack only, and parents provide the lucnch. LPA observed children’s lunches to be labeled, with each individual children’s names on it. Per licensee, they are aware of children enrolled with allergies and dietary restrictions. LPA observed knives to be made inaccessible to children. LPA observed child safety gates installed.

LPA reviewed 5 child’s records which were complete. LPA reviewed licensee’s and staff present records, which were complete. Licensee has a current Mandated Reporter certification and a CPR/First Aid certification. Mandated Reporter certification will expire 3/16/2027. Licensee’s CPR/First Aid will expire 01/2026.

Emergency disaster drills are conducted and are appropriately documented. Last disaster drill was conducted 02/08/2025. LPA observed licensing documentation to be properly posted, made available for review. Facility maintains a childcare roster that was also made available for review. Per licensee, there are no weapons or firearms in the home.

Based on observation and file review, one of the staff assistants who is pending background fingerprint clearance working with children.

There is one deficiency sited during today’s inspection. Per California Code of Regulations, Administration of Child Care Licensing 1596.871 (c)(1)(A) One-Type A citation.

LPA Zaragoza informed Licensee, Andres Martinez Segovia that this report dated 03/21/2025 document(s) (1) Type A citation(s) which shall be posted for 30 consecutive days as there is immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA Zaragoza informed the licensee to provide a copy of this licensing report dated 03/21/2025 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

(Continue Report on Page 3...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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: MARTINEZ SEGOVIA, ANDRES	FACILITY NUMBER: 384004808
	VISIT DATE: 03/21/2025

NARRATIVE

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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.

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.

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.

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/.

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.

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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: MARTINEZ SEGOVIA, ANDRES	FACILITY NUMBER: 384004808
	VISIT DATE: 03/21/2025

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During the exit interview, the licensee, Andres Martinez Segovia, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed a Megan’s Law search on 03/21/2025.

Based on interviews, observations and record review, the licensee did not comply with California Code of Regulations Title 22 1596.871 (c)(1)(A) . The licensee is being cited 1 Type A violation. See attached 809D.

A POC was discussed with licensee. Appeal Rights were provided during visit.

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

Exit interview conducted and report was reviewed with the licensee, Andres Martinez Segovia

Report was translated in Spanish.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/21/2025 03:07 PM - It Cannot Be Edited

Created By: Melissa Zaragoza On 03/21/2025 at 02:49 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: MARTINEZ SEGOVIA, ANDRES	FACILITY NUMBER: 384004808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1596.871(c)(1)(A)

Administration of Child Day Care Licensing

Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by having an unfingerprinted adult working with children, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/22/2025
	Plan of Correction
1 2 3 4	Licensee informed the staff assistant they had to leave the premisis and can not return to work until fingerprint clearance is obtained.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Melissa Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC809 (FAS) - (06/04)

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