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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002946
Report Date: 05/30/2025
Date Signed: 05/30/2025 01:51:10 PM

Document Has Been Signed on 05/30/2025 01:51 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:TRINITY LUTHERAN PRESCHOOLFACILITY NUMBER:
414002946
ADMINISTRATOR/
DIRECTOR:		EYVAZOV, JAMFACILITY TYPE:
850
ADDRESS:1505 SHERMAN AVENUETELEPHONE:
(650) 580-2349
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 28TOTAL ENROLLED CHILDREN: 28CENSUS: 0DATE:
05/30/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:33 AM
MET WITH:Jam EyvazovTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On May 30, 2025 at approximately 8:25AM, Licensing Program Analyst (LPA) Katie Krenn arrived at the facility to conduct an unannounced annual continuation visit. LPA met with the director, Jam Eyvoazov and explained the purpose of today's visit. Present at the facility in addition to the director were four staff. No children were present today. Today is a parent - teacher conference day.

Days and hours of operation: Monday - Friday 8:00AM - 5:30PM.
Facility has three classrooms, two bathrooms, a lunch room, and an outdoor play area.

The facility has a centralized smoke alarm and carbon monoxide detector in each room, and working telephones. The fire department inspected the smoke alarm system in March 2025.

The facility has two first aid kits, one is stored in doors and the other is stored outdoors, so they are easily accessible. LPA observed three charged fire extinguishers and portable emergency disaster supplies. The most recent emergency disaster drill was conducted in May 2025, and the LPA observed that it was documented. LPA reviewed the emergency disaster drill log and found that drills were conducted at least once every six months.

LPA inspected the indoor and outdoor areas for health and safety hazards. The facility is in good repair and has proper temperature and ventilation. LPA observed that the facility was clean, safe, and well-maintained. Disinfectants, cleaning solutions, and poisons were securely stored out of children's reach, and all accessible cabinets and drawers in the classrooms were free of hazardous materials.
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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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: TRINITY LUTHERAN PRESCHOOL
FACILITY NUMBER: 414002946
VISIT DATE: 05/30/2025
NARRATIVE
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Per the director the facility utilizes a Bright-wheel app for sign-in/out for parents or authorized representatives; unique sign-in/out codes are provided to each parent or other authorized persons.

LPA observed that the three classrooms and lunch room had age-appropriate toys, furniture, and educational materials. LPA observed that each child has their own cubby, labeled with their name, available for the storage of their personal belongings.

LPA observed that the facility offers cots for children to rest or nap. Per the director, each child has their own cot, bedding is provided from home, is stored in their personal cubbies when not in use, and goes home with children on Fridays for laundering.

LPA observed that floor vents for central heating and cooling were accessible. LPA observed electrical outlets are covered. There are two bathrooms with child sized toilets and child level sinks. The facility had a changing table near a sink.

Per the director, each child has their own water bottle which is filled at the facility from water filters. The water bottles are carried in a caddy so they can be brought outside during outdoor play and accessible to the children.

The preschool program currently provides lunch and snacks for the children. LPA saw that posted menus included healthy options such as fresh fruits, vegetables, and whole grains. Meals and snacks are prepared on site. LPA inspected the kitchen where the food is prepared. The kitchen is inaccessible to the children in care and clean and orderly. LPA did not observe any toxic substances or pests in the kitchen. LPA observed that perishable food was proper stored in the refrigerator and freezer.

The outdoor playground is surrounded by a fence that is at least four feet tall. The play equipment is in good condition and does not have sharp, loose, or pointed parts. The areas around and under climbing equipment and slides are cushioned with artificial grass. In the outdoor play area, LPA observed a hole on the side of the yard, approximately 18" in diameter and about 8" deep. Per the grounds keepers/maintenance persons, the hole is from a tree that was removed last year. Per the director, the hole will be filled in and covered with artificial grass this summer. There are no pools, spas, or bodies of water on the property.
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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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: TRINITY LUTHERAN PRESCHOOL
FACILITY NUMBER: 414002946
VISIT DATE: 05/30/2025
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Since LPA reviewed five staff and eight children's files during the annual visit on April 29, 2025, LPA did not review additional staff or children's files during this continuation visit. During the previous visit LPA found that one child's Admission Agreement was not in their file and two children's Person Rights forms not in their file. Also, during the previous visit, LPA found that one staff member was missing the Health Screening form and a complete immunization record. Two other staff members' records of MMR vaccination or immunity was not in their file. During today's visit LPA reviewed these records to ensure that they had been completed since the last visit. LPA verified that the two staff missing MMR vaccination had proven immunity. The staff member did complete the health screening, but TB testing was not documented and the vaccination record available for review was incomplete.

LPA reminded the director to call the licensing office to inform them of any changes to the hours of operation, such as holidays that are not observed by state employees, minimum days, or parent teacher conference days.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.

Director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the director, Jam Eyvazov.
NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/30/2025 01:51 PM - It Cannot Be Edited


Created By: Katie Krenn On 05/30/2025 at 12:20 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: TRINITY LUTHERAN PRESCHOOL
FACILITY NUMBER: 414002946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of five persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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The staff member will provide test results for tuberculosis and will provide verification of MMR vaccination or immunity.
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.
Daniel J Oquendo
NAME OF LICENSING PROGRAM MANAGER:
Katie Krenn
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
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