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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001205
Report Date: 12/03/2025
Date Signed: 12/03/2025 05:08:19 PM

Document Has Been Signed on 12/03/2025 05:08 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:WILSON,SANDRA, GUBATON,XIANNE, & GONZALES,VERONICOFACILITY NUMBER:
414001205
ADMINISTRATOR/
DIRECTOR:		SANDRA W. & VERONICO G.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 573-1565
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 11DATE:
12/03/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:55 PM
MET WITH:Licensee, Veronico GonzalesTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
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On 12/3/2025, at approximately 2:55PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA met with co-licensee, Veronico Gonzales (L1), and explained the purpose of the visit. Present during the visit was L1, co-licensee Xianne Gubaton (L2), 1 helper, 2 resident adults, 9 preschool age children, and 2 infants. Co-licensee Sandra Wilson (L3) was not present during today’s visit. The facility is operating within staffing and ratio requirements on this day.

Daycare Areas: Living Room, Kitchen, Bathroom #1, Backyard and Garage (converted into classroom).
Off-limits Areas: Bedroom #1, Bedroom #2 and Bedroom #3, and Bathroom #2 (attached to Master Bedroom).

LPA and L1 inspected the home for any health or safety hazards. The home is equipped with 2 fully charged 2A10BC fire extinguishers. There is an operational carbon monoxide detector present in the Garage. Outlets are blocked or covered when not in use. There is a fireplace in the Living Room that is blocked and inaccessible. Poisons, cleaning detergents, and other chemicals are stored inaccessible to children in care. There are temperature and ventilation controls available for the comfort and safety of children in care. The surface of the facility was observed to be free of debris and other loose articles. Off-limits areas are kept inaccessible with childproof gates.

LPA observed there to be age-appropriate toys and learning materials present. Furniture is age-appropriate and free of rough or sharp edges. The facility provides cots and bedding for children to use. Per L1, bedding is cleaned once a week or as needed. Cots are wiped down once a week. Per L1, the facility provides all meals for children in care. Water bottles are brought from home. Storage of medication was reviewed. LPA advised that medication be checked for expiration dates, and returned to parents for disposal. L1 stated that they understood.
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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2025
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: WILSON,SANDRA, GUBATON,XIANNE, & GONZALES,VERONICO
FACILITY NUMBER: 414001205
VISIT DATE: 12/03/2025
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The Backyard was observed to be free of debris and other loose materials. Equipment is age-appropriate and free of rough or sharp edges. Play structures are cushioned with resilient padding. The Backyard is enclosed by a fence that is at least four feet high. There are no swimming pools or other similar bodies of water present in the facility. There are no firearms or weapons stored in the facility.

LPA reviewed 3 staff files, 6 children’s files, and facility records. There is at least one staff member present with current Pediatric First Aid/CPR training. LPA advised that ALL licensees shall complete Pediatric First Aid/CPR training and maintain documentation in their files. Mandated Reporter trainings are current and expire by 12/31/2025. LPA advised that all staff members must complete Pediatric First Aid/CPR training and Mandated Reporter training every two years. All adults living or present in the home must have documentation of tuberculosis clearance.

Children’s records were observed to contain Emergency Identification and Information (LIC700). Sleep logs are not maintained for children under 24 months of age. A sample sleep log was provided. Sleep logs are to be conducted and recorded every 15 minutes. LPA informed L1 that a deficiency shall be cited today. A plan of correction was discussed and agreed upon.

Required postings were observed to be posted in the Living Room and the Garage. LPA advised that required postings be moved to the wall adjacent to the main entrance of the home so that parents have access to them. L1 stated that they understood.

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.




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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
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: WILSON,SANDRA, GUBATON,XIANNE, & GONZALES,VERONICO
FACILITY NUMBER: 414001205
VISIT DATE: 12/03/2025
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for and removing any 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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. 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 are 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.

During the exit interview, co-licensee Veronico Gonzales confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

See LIC809-D for deficiency cited today regarding infant sleep logs. See LIC9102-TV for technical violations issued today regarding records. Appeal rights were provided and explained. A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with the co-licensee, Veronico Gonzales.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/03/2025 05:08 PM - It Cannot Be Edited


Created By: Jonathan Tse On 12/03/2025 at 04:47 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: WILSON,SANDRA, GUBATON,XIANNE, & GONZALES,VERONICO
FACILITY NUMBER: 414001205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above for 2 out of 2 infants enrolled, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Licensee shall log and document infant sleep logs. Documentation of three days worth of sleep logs for enrolled infants shall be sent to LPA via email by set due date of 12/19/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Jonathan Tse
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2025


LIC809 (FAS) - (06/04)
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