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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002373
Report Date: 07/03/2025
Date Signed: 07/03/2025 01:21:01 PM

Document Has Been Signed on 07/03/2025 01:21 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:CHAVEZ-CRUZ, DELMA & MEDINA, MARCELAFACILITY NUMBER:
414002373
ADMINISTRATOR/
DIRECTOR:		D. CHAVEZ-CRUZ & M. MEDINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 685-6645
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 11DATE:
07/03/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Marcela Medina&Delma Cruz Chavez TIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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On July 3, 2025, Licensing Program Analyst (LPA) Zeynep Basak conducted a case management inspection in response to an incident involving a child attending the daycare facility. The purpose of the inspection was to gather additional information. LPA met the licensees, Marcela Medina and Delma Cruz Chavez and explained the purpose of the inspection.

Present at the facility during the inspection were the licensees, the assistant, and 11 children (2 infants, 4 toddlers, and 5 preschoolers).

The licensees stated that five adults, including themselves, live in the home. The LPA verified that all individuals currently residing in the home have criminal background clearance through the Guardian Website.

LPA interviewed the licensees and obtained pertinent documents.

Additional information may be required, and the investigation may still be ongoing.

During the inspection, LPA observed that the licensees were informed of the incident on June 15, 2025, however, the incident was not reported to the CCL department. A Type B violation will be issued today.

An exit interview was conducted with the licensees, Marcela Medina, and Delma Cruz Chavez, and a copy of the report was provided.

The Notice of Site Visit was issued and must remain posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Zeynep Basak
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
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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Document Has Been Signed on 07/03/2025 01:21 PM - It Cannot Be Edited


Created By: Zeynep Basak On 07/03/2025 at 12:40 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: CHAVEZ-CRUZ, DELMA & MEDINA, MARCELA
FACILITY NUMBER: 414002373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2025
Section Cited
CCR
102416.2(c)(1)

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102416.2 (c)(1)Any suspected child abuse or neglect, as defined in Penal Code Section 11165.6, of any child in care, in addition to reporting requirements pursuant to Penal Code Section 11166.
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LPA discussed the regulation, and the licensees acknowledged the reporting requirement regulation.
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Based on observation and record review, the licensees did not comply with the section cited above in reporting the suspected child abuse to the CCL department, which 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.
Daniel J Oquendo
NAME OF LICENSING PROGRAM MANAGER:
Zeynep Basak
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


LIC809 (FAS) - (06/04)
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