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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004777
Report Date: 08/25/2025
Date Signed: 08/25/2025 11:49:54 AM

Document Has Been Signed on 08/25/2025 11:49 AM - 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:CREATIVE LEARNING PRESCHOOLFACILITY NUMBER:
414004777
ADMINISTRATOR/
DIRECTOR:		YA CHIEN KOFACILITY TYPE:
850
ADDRESS:3399 CSM DRIVETELEPHONE:
(415) 860-3386
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 23TOTAL ENROLLED CHILDREN: 23CENSUS: 2DATE:
08/25/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Judy Ko TIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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On 8/25/2025 at 8:45AM., Licensing Program Analyst (LPA), Luis Gomez met with Director, Judy Ko. The purpose of today's visit was explained and was for an unannounced- annual random inspection. Present was director, and 1 staff supervising 2 children. Facility’s days and hours of operation are Monday- Friday, 8:00AM- 6:00PM. The preschool program utilizes 2 classrooms: 105, 106, and one outdoor play area. LPA inspected facility, indoors and outdoors, for health and safety hazards.

At 9:05AM., LPA observed the following: classrooms were neat and orderly, with age-appropriate playthings available for the children. Facility doorways, floors, and surfaces were clean and clear of obstructions. Classrooms equipped with several activity areas for the children. Classrooms have several tables/ chairs, and stepping stools; scaled to the appropriate size. The books, supplies, and puzzles inspected were in good repair. Labeled cubbies are available for storage of belongings. Children’s bathrooms was observed safe and sanitary. LPA reminded director to remove cleaning supplies from children's bathroom. The toilets and faucets inspected are in operating condition. LPA observed diaper changing tables available for the staff in classroom, 106; and is within arm’s reach of a sink. Trash bins used for solid waste had been covered.

For nap/ scheduled rest, stackable cots are stored in facility shed. LPA advised director to use cots during daily nap time.

The facility has adequate ventilation, lighting, and was a comfortable temperature. Facility had a functioning telephone service; carbon monoxide detector; and fire extinguisher (3A40BC). (REFER TO 809C, FOR CONT.)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2025
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: CREATIVE LEARNING PRESCHOOL
FACILITY NUMBER: 414004777
VISIT DATE: 08/25/2025
NARRATIVE
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(PAGE 3)
Assembly Bill (AB) 2370, chapter 676, statues 2018 requires all licensed child care 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.

LPA verified that the lead testing was completed in accordance with the Written Directives outlined in PIN21-21- 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 22-02CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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/.

Director, Michelle Lee 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 Child Care Center. A civil penalty of $100.00 minimum/ day for maximum of 5 days or, if the penalty is repeat violation, for a maximum of 30 days per person will be assessment if this regulation is violated.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website athttps://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

Based on today's inspection, deficiencies were observed in the areas evaluated according to the Title 22 Division 12 Chap. 1 Ca. Code of Regulations and cited on 809D.

An exit interview discussing the facility evaluation report and plans for correction were conducted with Director, Judy Ko, and signature on this form acknowledges the receipt of these documents.

This report must be made available in facility for public review. Notice of site visit was provided and must remain posted for 30 days. Director was advised, any additional questions/ concerns to contact the San Bruno Regional Office, Mon-Fri, 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: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
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: CREATIVE LEARNING PRESCHOOL
FACILITY NUMBER: 414004777
VISIT DATE: 08/25/2025
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(PAGE 2)
At 9:20AM, LPA reviewed the outdoor play area. LPA observed absorbent material installed on ground surfaces around structure, and was completely enclosed with tall fencing. An area for shaded rest is available for the children, and the climbing structure had been properly anchored.

Per director, drinking water is readily available outside and inside for children to drink as they wish.

At 9:35AM., LPA reviewed the facility records including the children and personnel files.

The personnel files reviewed contained: Notice of Employee Rights (LIC9052); and Acknowledgement to Report Suspected Child Abuse (LIC9108).

LPA reminded director to ensure staff proof of immunization are stored in facility records.

At 10:00AM., Based on record review, LPA confirmed director's CPR/ 1st aid course has expired. Per director, course will be renewed on 8/30/2025. Advisory Note: Technical Violation (LIC9102TV) was issued.

At 10:05AM., Based on record review, LPA confirmed children files (C1, C2) missing from facility records.

Facility emergency disaster drill are completed every 6 months, with last drill done on: 8/15/2025.

Required postings in facility and included the: Facility License; Notification of Parent’s Rights (PUB394); Personal Rights (LIC613A); The Passenger Safety Laws (PUB269); Lead Testing Results; and Emergency Disaster Plan (LIC610).

Per director the isolation of an ill child is in the lobby area.

At 10:50AM., Based on observation, record review, and observation, LPA confirmed unqualified staff (S2) left alone with day-care children. Advisory Note: Technical Violation (LIC9102TV) was issued. (REFER TO 809C, FOR CONT.)

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

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/25/2025 11:49 AM - It Cannot Be Edited


Created By: Luis Gomez On 08/25/2025 at 11:39 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: CREATIVE LEARNING PRESCHOOL
FACILITY NUMBER: 414004777

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(a)
(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 10:05AM., Based on record review, LPA confirmed children files (C1, C2) missing from facility records. This poses a potential health and safety risk to children in care.
POC Due Date: 09/08/2025
Plan of Correction
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Director will submit missing licensing forms for children (C1, C2) to the Department by the due date: 9/8/2025
LPA provided licensing forms to the Director. Proof of correction will be submitted to the Department via email.
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.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Luis Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2025


LIC809 (FAS) - (06/04)
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