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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004686
Report Date: 05/28/2026
Date Signed: 05/28/2026 04:36:15 PM

Document Has Been Signed on 05/28/2026 04:36 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:IHSD LAKEWOOD CHILD DEVELOPMENT CENTERFACILITY NUMBER:
414004686
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, JOHNFACILITY TYPE:
850
ADDRESS:69 TOWER ROADTELEPHONE:
(650) 504-9928
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 7DATE:
05/28/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:John FernandezTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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On 5/28/2026 at 12:55PM., Licensing Program Analyst (LPA), Luis Gomez met with Director, John Fernandez. The purpose of today's visit was explained and was for an unannounced, annual-random inspection. This facility is licensed preschool-age program located at the San Mateo County Office of Education. The day and hours of operation are Monday- Friday, 8:00AM- 4:00PM. Present was Director and 3 staff supervising 7 children. Per director, children’s present had been signed in by authorized representative. The staff presents have criminal record clearances on file. The program utilizes one classroom: Room #2, and one outdoor play yard. Per Director, childcare program operates year-round. LPA inspected facility, indoors and outdoors, for health and safety hazards.

At 1:10PM., LPA observed the following: The facility was neat with age-appropriate equipment and materials available for the children. All floor surfaces, carpets and exit pathways were clear of obstructions or hazards. The accessible furniture and playthings inspected were in good repair, and free of sharp corners or splintered edges.

The classroom had labeled cubbies children’s belongings, and available extra cabinets for storage of classroom supplies. LPA observed tables and several chairs scaled to the appropriate size.

The bathroom was observed clean with adequate supplies for washing hands. The classroom had a changing table available for the staff as needed. The accessible trash bins, designated for the disposal of solid waste had been covered. Per director, solid waste is removed daily from classroom.

The facility had adequate ventilation, was properly lit, and maintained at a comfortable temperature. The facility had a functioning telephone service; carbon monoxide/ smoke combination detector; and fire extinguisher (2A:10BC) inside the classroom. The detergents, spray bottles, and cleaning wipes have been made inaccessible, stored on out of reach shelf.

The classroom’s food storage area was reviewed during inspection. The area was observed clean and free of trash or rubbish. The food items inspected were current and had been properly stored in refrigerator. Per director, all meals are brought to the site daily by third-party vendor (Chefables). The meals services provided include: Breakfast, Lunch and PM Snack. (REFER TO 809C, FOR CONT.)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2026
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 5
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: IHSD LAKEWOOD CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 414004686
VISIT DATE: 05/28/2026
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(Page 2)
At 1:35PM., LPA inspected the enclosed outdoor play yard. The climbing structure was observed securely anchored, and absorbent material (rubber padding) was installed underneath. Per director, for water service disposable cups and are available for children to drink as they wish.

The LPA advised director to ensure hazardous material, small rubber granules, are removed from sand area prior to use. An Advisory Note: Technical Violation (LIC9102TV) was issued.

At 2:10PM., LPA reviewed facility records including 3 children’s files and 3 personnel files. The staff files contained the: Notice of Employee Rights (LIC9052); Acknowledgement to Report Suspected Child Abuse (LIC9108); Teacher Qualification; Proof of Immunization; and Personnel Record (LIC501).

The staff present had renewed the required mandated reporter training course (AB1207).

The children’s files were reviewed and included the: Consent for Medical Treatment (LIC627- Internal); Identification of Emergency Information (LIC700- Internal); Immunization Record; Notice of Parent's Right (LIC995); Personal Right Form (LIC613A); and the Signed Admissions Agreement.

LPA reminded director to store children’s medical record/ physician’s assessments inside the facility files. The children's medication and storage was reviewed during inspection.

The staff CPR/ 1st Aid Certifications were current, expiring on: 3/2027. The facility emergency disaster drill (Fire and Earthquake drill) was completed on: 4/22/2026.

The required posting were posted in lobby and include License Certificate; Notification of Parents Rights (LIC995A); Menu (May, 2026); Personal Rights Form; Outdoor Space Waiver for Rotational Use; and CA Seat Belt Safety Laws (REFER TO 809C, FOR CONT.)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: IHSD LAKEWOOD CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 414004686
VISIT DATE: 05/28/2026
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(PAGE 3)
Assembly Bill (AB) 2370, chapter 676, statues 2018 requires all licensed childcare centers (CCC’s) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and every five years after the date of the first test. The LPA has verified that lead testing procedure was completed in accordance with the Written Directives outlined in PIN 21-21- CCP.

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/.

The director was reminded that all adults 18 and over, 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 Child Care Center. 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.

The director 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.

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.

Based on today's inspection, no deficiencies were cited in the areas evaluated, according to Title 22 California Code of Regulation (CCR) and Health and Safety Code (HSC). An exit interview was conducted including a review of facility evaluation report (FER) with Director, John Fernandez. The signature of this form acknowledges receipt of these documents.

This report and rights to comment were discussed. This report must be available in the facility file for public review. The Notice of site visit was provided and must remain posted for 30 days. The director was advised for additional questions to contact the San Bruno Regional Office, M-F, 8:00am-5:00pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC809 (FAS) - (06/04)
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