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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004876
Report Date: 12/08/2023
Date Signed: 12/08/2023 03:39:41 PM

Document Has Been Signed on 12/08/2023 03:39 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:LOPEZ GUZMAN, DAISY N.FACILITY NUMBER:
414004876
ADMINISTRATOR:LOPEZ GUZMAN, DAISY N.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 520-1249
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
12/08/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Daisy Lopez GuzmanTIME COMPLETED:
03:50 PM
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On 12/8/2023 at 2:30PM., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee Daisy Lopez Guzman. Purpose of inspection was explained and was for a Case Management inspection to add bedroom #2 to licensee's on-limit areas. Licensee requests to remove Bedroom #1 (Napping Only). Present was the Licensee, Licensee’s Husband and Helper caring for 3 children. 2 children arrived during inspection. (3 infant- age, 2 school- age). LPA inspected home with licensee for health and safety hazards.

At 2:35PM., LPA observed the following: Bedroom #2 was clean with age-appropriate plaything available. Licensee had three cribs/ play pens, with tight-fitting sheets. Floor was clear of any obstructions, and furniture was in good repair. Storage closet was reviewed during inspection.

On 11/30/2023, Licensee submitted updated Facility Sketch (LIC999) to the Department. 'Letter of Deficiency Citation Cleared' was given during inspection.

LPA reminded license to ensure cribs are maintained free of loose articles and objects.

On, 12/8/2023, Bedroom #2 has been added to the on-limit areas.

**No deficiencies were cited against the facility today under CCR, Title 22, Div. 12, Chapter. 3**



Report was reviewed and copy was issued to Licensee, Daisy Lopez Guzman. This report will be kept in the facility file and made available for public review upon request.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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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