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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004674
Report Date: 12/18/2023
Date Signed: 12/18/2023 12:23:53 PM

Document Has Been Signed on 12/18/2023 12:23 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,MARILU V.FACILITY NUMBER:
414004674
ADMINISTRATOR:HERNANDEZ, MARILU V.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 773-8427
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 13DATE:
12/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Licensee, Marilu HernandezTIME COMPLETED:
12:45 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 December 18th, 2023, at approximately 11:40am, Licensing Program Analyst, (LPA) Tapia-Mandujano conducted a concurrent inspection along with a complaint investigation and met with Licensee, Marilu V. Hernandez. Present in the facility are licensee and assistant supervising a total of 13 children (4 infants and 9 preschool age children). Facility is not operating within capacity limits. All adults present in the facility are fingerprint cleared and associated.

During the health and safety check, LPA observed that there were 4 infants and 9 preschool age children present in the facility. LPA reviewed childrens' files to ensure that ages of the children present. Refer to LIC 809D for deficiency information. LPA explained to Licensee, the capacity limitations.

LPA informed licensee Marilu V. Hernandez that this report dated 12/18/23 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 Marilu V. Hernandez to provide a copy of this licensing report dated 12/18/23 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 to Spanish by LPA Tapia-Mandujano with the licensee, Marilu V. Hernandez

Due to technical difficulties LPA was unable to print report. Report will be emailed to licensee. .
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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 2
Document Has Been Signed on 12/18/2023 12:23 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 12/18/2023 at 12:02 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: HERNANDEZ,MARILU V.
FACILITY NUMBER: 414004674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2023
Section Cited
CCR
102416.5(a)

1
2
3
4
5
6
7
102416.5(a): Staffing Ratio and Capacity: The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility must reduce capacity to the maximum number of children for whom care may be provided at any given time. At any given time there could be no more than 4 infants and 8 preschoolers, or no more than 3 infants 9 preschoolers, and 1 or 2 school age children.
8
9
10
11
12
13
14
Based on observation and record review, the licensee did not comply with the section cited above as during today's inspection there are 4 infants and 9 preschool age child present which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Licensee will submit proof of a schedule of children to prove that facility is not operating overcapacity.

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.
SUPERVISOR'S NAME:Marie Rodriguez
LICENSING EVALUATOR NAME:Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2