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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410517924
Report Date: 03/12/2026
Date Signed: 03/13/2026 01:38:54 PM

Document Has Been Signed on 03/13/2026 01:38 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:PENINSULA COVENANT CHURCH AFTERCAREFACILITY NUMBER:
410517924
ADMINISTRATOR/
DIRECTOR:		CARRION, MEGANFACILITY TYPE:
840
ADDRESS:3560 FARM HILL BLVD.TELEPHONE:
(650) 365-8094
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 140TOTAL ENROLLED CHILDREN: 140CENSUS: DATE:
03/12/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:46 PM
MET WITH:Setareh PoovanTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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On March 12, 2026 @ approximately 12:45pm, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an unannounced Case management visit and met with Acting Director Setareh Poovan and explained the purpose of the inspection.

LPA has been working with Acting Director for several months to collect all required documents for qualified Director. LPA has only received partial packet for Director. LPA gave Acting Director a deadline of March 11, 2026, to submit missing documents. As of this date complete Director Licensing packet has not been submitted.

During today’s visit, LPA collected LIC 308, for Director and Director designee. Based on interview during today’s visit, Pesticides training, preventative health and safety have not been completed. Director packet is also missing documentation of work experience from previous employers. LPA cited a type “B”, as this poses a potential health, safety and personal rights risk to children in care.

Please see page LIC809D for type “B” deficiency issued today under California Code of Regulations, Title 22, Division 12.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements may result in an immediate civil penalty of $100. This report is public and can be reviewed.

Exit interview was conducted and report was reviewed with Acting Director, Setareh Poovan. Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2026
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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Document Has Been Signed on 03/13/2026 01:38 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 03/12/2026 at 01:48 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: PENINSULA COVENANT CHURCH AFTERCARE
FACILITY NUMBER: 410517924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/26/2026
Section Cited
CCR
101215.1(b)

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101215.1:Child Care Center Directors Qualifications and Duties: (b) All child care centers shall have a director.

This requirement is not met as evidenced by:
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Facility must submit proof of fully qualified director to LPA by 3/26/26. Documentation must include Preventative Health and Safety certificate, Pesticides training certificate and documentation of work experience from previous employers

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Based on observation, interview, and record review, the facility did not comply as the facility does not have a qualified director. Complete Director's packet has not been received and LPA has requested documentation via numerous email dating back to 11/24/2025. This poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Maria Olguin-Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


LIC809 (FAS) - (06/04)
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