<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001369
Report Date: 05/15/2026
Date Signed: 05/26/2026 04:07:23 PM

Document Has Been Signed on 05/26/2026 04:07 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:HERNANDEZ, ROSARIO INGRIDFACILITY NUMBER:
414001369
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, ROSARIO INGRIDFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 229-3798
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
05/15/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Licensee, Rosario Ingrid HernandezTIME VISIT/
INSPECTION COMPLETED:
12:50 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 May 15, 2026, at approximately 9:40am, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced case management-Incident visit. LPA met with licensee, Rosario Ingrid Hernandez, and explained the purpose of the visit. Upon entering the facility, licensee was alone with 9 children (3 infants and 6 preschoolers). LPA observed assistant enter the home shortly after. Facility was operating outside of license capacity as assistant was not present. Type A citation was received. During inspection, LPA observed all adults present have fingerprint clearance and are associated to roster.

Hours of operations are Monday through Friday 8:00am to 5:00pm. Daycare areas are: Living Room (Playroom #1), Bedroom #1 (for napping only), Bathroom #1 and enclosed Outdoor Play Area. Off Limit areas are: Bedroom #2, Bedroom #3, Family Room, and Kitchen (Pass through only). All off limit areas, including all closets, are properly barricaded.

Department received a cross-report of an incident that occurred on 11/10/25 where Emergency Services had to be called for Child 1 (C1) due to a Medical Emergency. Per licensee, C1 suffered an unexpected medical emergency while in care. During today inspection, LPA obtained all the necessary information about the incident and received pertinent documentation. Based on information received, licensee was proactive and performed the necessary steps to support the safety of C1, that included informing the parents. C1 has since returned with no restrictions and has been medically cleared.

During inspection, LPA explained the importance of reporting requirements as licensee failed to report this incident to the Department. LPA went over the regulations of reporting requirements and explained the steps that must be taken. LPA also explained and provided a copy of the LIC 624B, Unusual Incident/Injury Report to licensee.

Continued on Page 2...

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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)
Page: 2 of 4
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: HERNANDEZ, ROSARIO INGRID
FACILITY NUMBER: 414001369
VISIT DATE: 05/15/2026
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
26
27
28
29
30
31
32
Page 2 Continued...

Deficiency was cited today under CCR, Title 22, Div. 12, Chapt. 1 for not following license capacity. Refer to LIC 809D for more details. Appeal rights were provided to licensee.

LPA informed licensee Rosario Ingrid Hernandez that this report dated 05/15/26 documents a Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA informed the licensee Rosario Ingrid Hernandez to provide a copy of this licensing report dated 05/15/26 that documents any Type A citations 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.

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

Exit interview conducted and report was reviewed and translated into Spanish with licensee, Rosario Ingrid Hernandez.

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/26/2026 04:07 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 05/15/2026 at 11:55 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: HERNANDEZ, ROSARIO INGRID
FACILITY NUMBER: 414001369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2026
Section Cited
CCR
102416.5(d)(e)

1
2
3
4
5
6
7
102416.5: Staffing Ratio and Capacity: (d) "For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home... (e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home..."


This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee's assistant walked in the door shortly after LPA walked in bringing the capacity back within compliance.

LPA explained to licensee that if she does not have any assistant present, no matter how long of a time, she must operate within the capacity of a Small Family Child Care Home.
8
9
10
11
12
13
14
Based on observation, interview, and record review, the licensee did not comply with the section cited above as upon arrival licensee was operating as Large Family Child Care License with no assistant present as she was supervising a total of 9 children (3 infants and 6 preschoolers) by herself. This poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Licensee will submit a written procedure/declaration on how she will ensure that there is always an assistant present helping care and supervise children if she is operating a capacity of a Large Family Child Care Home.

Follow up visit is required.

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.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Leslit Tapia-Mandujano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4