414001051-1-23-2026-05-CC-KKRN-DQLQEC-20260123110606

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414001051
Report Date: 01/23/2026
Date Signed: 01/23/2026 11:06:16 AM

Document Has Been Signed on 01/23/2026 11:06 AM - 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:	PFS- HAVEN CDC (PS)		FACILITY NUMBER:	414001051
ADMINISTRATOR/ DIRECTOR:	SHEPARD, TERI		FACILITY TYPE:	850
ADDRESS:	260 VAN BUREN AVENUE		TELEPHONE:	(650) 555-1212
CITY:	MENLO PARK	STATE: CA	ZIP CODE:	94025
CAPACITY: 24	TOTAL ENROLLED CHILDREN: 18	CENSUS: 15	DATE:	01/23/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:17 AM
MET WITH:	Olga Martinez Chavez		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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 January 23, 2026 at approximately 8:00AM Licensing Program Analyst, (LPA) Katie Krenn arrived at the facility for an unannounced case management visit. LPA met with the Site Supervisor, Olga Martinez Chavez (D1) and explained the purpose of today's visit is to follow up on the recent incident that the facility self reported, where a child was briefly left without supervision. Present at the facility were five staff supervising 11 preschool children (ages 3-5 years old) and four toddlers (ages 2-3 years old). This is a Title V program. The facility remains within its capacity limits and meets the required ratios for today’s visit. All staff present at the facility during this visit have obtained criminal record clearance from the Department of Social Services. Program operates Monday through Friday from 7:00 AM - 5:45 PM year-round. Per D1, there are no pools, spas, or bodies of water on the property. LPA observed all the required postings in both classrooms in both English and Spanish. The facility had a first aid kit, a smoke detector, a fire pull alarm, a charged fire extinguisher, two carbon monoxide detectors, and an emergency disaster kit. LPA tested the carbon monoxide detectors that had been installed since the previous inspection. LPA found both of the new carbon monoxide detectors to be working properly. This facility uses an app for signing children in and out. LPA reviewed the sign in and sign out files and found that all the children present had been signed in. Each person designated to pick up children has their own unique pin. LPA conducted and interview with D1. The incident involved a toddler that was able to enter an empty classroom as a family was leaving the classroom, because the door was not latching properly when closed. The child was unsupervised in the classroom for approximately 30 seconds, before a teacher found him. continued on page 2

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

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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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: PFS- HAVEN CDC (PS)	FACILITY NUMBER: 414001051
	VISIT DATE: 01/23/2026

NARRATIVE

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The facility had physical bells on the inside of the doors and could hear the them from inside the classroom, but not outside the classroom. Per D1, the door was fixed on January 9, 2026. D1 also had electronic bells added. LPA tested both doors and observed that the electronic bells could be heard well from inside the classroom. LPA had the facility move the physical bells to the exterior of the door, because the electronic bells were less audible outside.

LPA tested the doors to ensure that they were closing properly. LPA tested the door after the physical bells were moved to the outside of the door that parents use to pick up and drop off children. LPA was able to hear the bells from outside the classroom.

Facility Representative was reminded that all adults 18 and over, 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 Child Care Center. 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.

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/.

Facility Representative 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.

To improve the quality and value of the 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.

A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with the Site Supervisor, Olga Martinez Chavez.

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2026 11:06 AM - It Cannot Be Edited

Created By: Katie Krenn On 01/23/2026 at 10:36 AM

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: PFS- HAVEN CDC (PS)	FACILITY NUMBER: 414001051
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/23/2026 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision: No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility will ensure that there is an audiable sound that can be heard from either side of the door, when the door is opened The facility will ensure that the door is in good working order.
	8 9 10 11 12 13 14	Based on the facility's self report, this requirement was not met as a child was left unsupervised inside a classroom for approximately 30 seconds. This poses a potential health and safety risk to children in care.	8 9 10 11 12 13 14	This citation was cleared the same day, since the facility had completed the POC to LPA's satisfaction during the visit.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Daniel J Oquendo
NAME OF LICENSING PROGRAM MANAGER:

	Katie Krenn
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC809 (FAS) - (06/04)

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