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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004890
Report Date: 02/21/2025
Date Signed: 02/21/2025 12:44:05 PM

Document Has Been Signed on 02/21/2025 12:44 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:SOBIESKI, GRACEFACILITY NUMBER:
414004890
ADMINISTRATOR/
DIRECTOR:		SOBIESKI, GRACEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 566-8595
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
02/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Neilyn Cory AbasoloTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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On February 21st, 2025., Licensing Program Analyst (LPA) Gil conducted an unannounced case management in conjunction with delivering the findings to complaint from November of 2024. LPA met with licensee Grace Sobieski. The purpose of this case management was explained to the Licensee. Present during LPA’s visit included licensee, licensee's spouse, 1 assistant, and 8 children (3 preschoolers, 2 school age, and 3 infants). The Department received information that an incident involving the Licensee and Spouse occurred early November 2024. The Licensee contacted Law enforcement at her home. After further review of the incident timeline, it was determined that there was a failure to report the unusual incident to Community Care Licensing as required. Per licensee, incident occurred over the weekend, and was unaware incident must be reported to department.

The following Title 22, Division 12, Chapter 1, Article 6 deficiency is being cited on the following page for failure to report the incident:

Licensee Grace Sobieski read and signed the report. Today's report, site visit notice, deficiency, and appeal rights were provided to the Licensee.

LPA informed the Licensee that a site visit notification must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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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Document Has Been Signed on 02/21/2025 12:44 PM - It Cannot Be Edited


Created By: Janet Gil On 02/21/2025 at 12:04 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: SOBIESKI, GRACE
FACILITY NUMBER: 414004890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2025
Section Cited
CCR
102416.2

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102416.2 Reporting Requirements
(b)The Licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. (C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child."
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Licensee will report any unusual incident report to Community Care Licensing using the LIC 624B Unusual Incident/Injury Report form and include details of any follow-up completed from when the Licensee is made aware of the incident. Licensee will review section 102416.2 of the Regulation regarding Reporting requirements and submit a plan to prevent this deficiency from reoccurrence.
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This requirement was not met, as evidenced by the record review. The Licensee failed to report to Community Care Licensing an unusual incident involving law enforcement being called and arriving at the home. Failure to report unusual incidences as required to the Department could present potential health and safety risks to the children.
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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.
SUPERVISOR'S NAME:Garfield Leung
LICENSING EVALUATOR NAME:Janet Gil
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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