384005030-4-10-2025-05-CC-MTSO-DFM2M4-20250410173032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384005030
Report Date: 04/10/2025
Date Signed: 04/10/2025 05:30:51 PM

Document Has Been Signed on 04/10/2025 05:30 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:	PACHECO, TINA		FACILITY NUMBER:	384005030
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	04/10/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:59 PM
MET WITH:	Tina Pacheco		TIME VISIT/ INSPECTION COMPLETED:	05:45 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 April 10, 2025, Licensing Program Analyst (LPA) Tso met with the Applicant, Tina Pacheco, for an announced pre-licensing inspection. The applicant was present at the home. The applicant rents these one-floor apartment unit on the ground floor, consisting of one bedroom, a bathroom, and a living / dining area and kitchen on the ground floor. The home resident is the applicant. The childcare area will be provided in the living / dining areas, a bedroom, bathroom, and kitchen. The off-limit areas are the Balcony/Patio, 2 closets and laundry room. The applicant states that this is their primary residence where they live full time. The days and hours of operation will be Monday - Friday, 8:30 am to 5:00 pm, and care for children between 15 months to four years old. Per the Applicant, she plans to utilize the bedroom as an isolation for sick/ill children. LPA and the Applicant inspected the entire home for Health and Safety Hazards. The house is clean and orderly and has sufficient lighting and ventilation. LPA observed a mattress in the closet in the bedroom. The applicants also placed the order for 4 mattress that to be arrived on 4/14/2025. LPA reminded the applicant to keep playpens and cribs free of toys, pillows, and hanging objects. Mattresses must be designed for playpens, and bed sheets should fit tightly. There are a variety of age-appropriate toys and puzzles for the children. All furniture and playthings were observed to be in good repair. (Continued on page 2...)

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Man Tso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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: PACHECO, TINA	FACILITY NUMBER: 384005030
	VISIT DATE: 04/10/2025

NARRATIVE

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The home has a combination smoke & carbon monoxide detector. During the inspection, the detector was tested and worked. All harmful objects, sharp objects, and toxins are stored out of the reach of children and made inaccessible to children. The Applicant states that no weapons, firearms, or pets are in the home. The home has no body of water, such as a swimming pool, spa, hot tub, or fishpond. All unused electrical outlets and electrical wires/power surges were observed covered.

LPA informed the Applicant that emergency drills are required every six months, and the Applicant must document the drills. The Applicant reminded that NO baby walkers, exer-saucers, jumpers, bouncers, and similar items are to be used for children in care and should be made inaccessible. In addition, booster chairs are only used for the purpose of feeding/eating. The Applicant was also reminded that smoking is prohibited at the daycare.

The Applicant plans to provide the children morning snacks, lunch, and afternoon snacks. Per the Applicant, she has not yet had a plan to purchase liability insurance for childcare. LPA informed the Applicant that if childcare insurance is not purchased, each parent must be given the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282). Applicant's Pediatric FirstAid and CPR, and Mandated Reporter Training are valid, and copies have been submitted to the Department.

LPA reviewed with the Applicant the LIC 311D, Forms/Records to Keep in Your Family Child Care Homes, children's forms/records, facility forms/records, and all required postings such as License/Parent's Right poster/Emergency Disaster Plan and Earthquake Preparedness checklist. In addition, the entrance Checklist was also provided to the Applicant. The Applicant plans to have all required posting on the front wall by the entrance of the patio. License capacity and limitation were also reviewed with the Applicant. LPA informed the Applicant that if care is provided to the 7^th and 8^th child, who must be school-aged, parent notification and landlord consent are required.
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NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Man Tso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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: PACHECO, TINA	FACILITY NUMBER: 384005030
	VISIT DATE: 04/10/2025

NARRATIVE

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LPA discussed the safe sleep regulations with the Applicant and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Applicant 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.

The applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

The applicant has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 6 [or 12] children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 8 [or 14] children.

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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.
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NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Man Tso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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: PACHECO, TINA	FACILITY NUMBER: 384005030
	VISIT DATE: 04/10/2025

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The Applicant was reminded 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 against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety Code 1596.7995 and 1597.662. The Applicant was encouraged to obtain a copy of regulations and current licensing forms through the Department's website at www.ccld.ca.gov. The Applicant was also reminded of Mandated Reporter Online Training for Child Care Providers (AB 1207) and the additional General Training, and both are available on www.mandatedreporteca.com.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders through Provider Information Notices (PIN), Program Quarterly Update Newsletters, and other important information communication platforms. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

The applicant was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Prior to recommended for licensure, application must complete the following for review:

- Proof of the installation of the child-proof stove switches knobs (4) on the stove in the kitchen
- Proof of an adult on the lease agreement that not living at the facility.
- Proof of the update Sketch (LIC999).
- Proof of moved in the facility for living.
- Proof of the installation of child proof lock on the closet at the main entrance.

The report was reviewed and signed by the Applicant, Tina Pacheco. Today's report was provided to the Applicant. This report will be kept in the facility file and available for public review upon request. Desk duty is available Monday - Friday, 8:00 a.m. – 5:00 p.m. (650) 266-8800. Website for Forms and Regulations: www.cdss.ca.gov

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Man Tso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC809 (FAS) - (06/04)

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