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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004898
Report Date: 09/09/2026
Date Signed: 09/09/2026 01:25:17 PM

Document Has Been Signed on 09/09/2026 01:25 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:ANNE CAMPBELL CHILD DEVELOPMENT CENTERFACILITY NUMBER:
414004898
ADMINISTRATOR/
DIRECTOR:		JENNY JANE LAMFACILITY TYPE:
850
ADDRESS:65 TOWER ROADTELEPHONE:
(650) 802-5616
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 10DATE:
09/09/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Olga Tereshenko, Jenny Lam, Anita TongTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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On 9/9/2026 at 8:40AM., Licensing Program Analyst (LPA), Luis Gomez met with Teacher, Olga Tereshanko. The purpose of today's visit was explained and was for an unannounced, annual-random inspection. The director, Jenny Lam, arrived during inspection. Present was Lead Teacher and 4 staff supervising 10 children. This is a licensed preschool program located in the San Mateo County Office of Education Building. The program utilizes three classrooms and two shared, outdoor play areas. The classrooms area are: Room #1, Room #3, and outdoor play areas: #1, Main Yard; #2, Secondary Yard. Per teacher, classroom #4 is not currently in use. Per teacher, days and hours of operation for classroom #3, (full-day) is Monday- Friday, 8:00AM- 5:00PM. Per teacher, days and hours of operation for classroom #1, (part-day) is Monday- Friday, 9:00AM- 1:00PM. LPA inspected facility, indoors and outdoors, for health and safety hazards.

At 9:05AM., LPA observed the following: The classrooms were neat and orderly, with age-appropriate materials available for the children. Each classroom had been divided into separate activity areas including reading areas, seating, and activity space. The floors, including carpets area and other ground surface were clear of obstructions or hazards. The accessible furniture, and playthings inspected were in good repair. The furniture was observed free of sharp corners or splintered edges. LPA observed several cubbies available for the children’s belongings.

The classrooms had several tables/ chairs, scaled to the appropriate size. For the nap/ schedule rest, stackable and cots were available inside classrooms. Per director, napping supplies (blankets) are taken home weekly by families to be washed and returned. Per director, the linens are washed onsite weekly. The children’s bathroom was maintained clean with liquid soap and paper towels available for hand washing. The LPA observed large changing table for staff use as needed. Per director, diaper are disposed in nearby solid waste bin, equipped with tight fitted lid.

The classrooms had adequate ventilation, were well lit and maintained at a comfortable temperature. The classrooms had a functioning telephone service, testable carbon monoxide/ smoke combination detector; and fire extinguisher size, 2A10BC in hallway. (REFER TO 809C, FOR CONT.)

Marie Rodriguez
Luis Gomez
DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2026
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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Document Has Been Signed on 09/09/2026 01:25 PM - It Cannot Be Edited


Created By: Luis Gomez On 09/09/2026 at 12:14 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: ANNE CAMPBELL CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 414004898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)
d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 10:45AM., Based on record review, LPA confirmed classroom #3 has not conducted emergency disaster drill within the last 6 months. This poses a potential health and safety risk to children in care.
POC Due Date: 09/18/2026
Plan of Correction
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The facility will conduct an emergency disaster drill by the due date: 9/18/2026.
The proof of correction will be submitted to the licensing analyst, 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: 09/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2026


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: ANNE CAMPBELL CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 414004898
VISIT DATE: 09/09/2026
NARRATIVE
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(Page 2)
At 9:45AM., LPA inspected both outside play areas: Primary and Secondary Play yards. The outside areas were completely enclosed with tall fencing. The LPA observed absorbent material (rubber padding) installed underneath the anchored climbing structure (Primary Play yard).

For water services, water bottles were available for children to drink as they wish. Per director, served water is from a non-contaminated fixture.

Per Teacher, food services are provided by an outside vendor, delivered daily and is heated on-site. The kitchen area was observed free of trash or rubbish, and current food items inspected were current.

This facility provides transportation services for children in care. LPA reviewed driver information, and license type during today’s annual inspection.

At 10:10AM., LPA reviewed facility records including sample of 5 children’s files and 7 personnel files. The staff files contained the: Notice of Employee Rights (LIC9052); Proof of Immunization; Acknowledgement to Report Suspected Child Abuse (LIC9108); Teacher Qualification; and Personnel Record (LIC501).

LPA reminded facility to ensure para-educator files are stored in facility and available for Department review. Advisory Note: Technical Violation (LIC9102TV) was issued.

The children’s files were reviewed and included the: Consent for Medical Treatment; Notification of Parents Rights (LIC995A); Identification of Emergency Information; Immunization Record; and Personal Right Form (LIC613A).

The director’s cardiopulmonary resuscitation and pediatric first aid certification was current, expiring on: 9/2027.

At 10:45AM., Based on record review, LPA confirmed classroom #3 has not conducted an emergency disaster drill within the last 6 months.

The required forms had been viably posted and included the: License Certificate; Notification of Parents Rights (LIC995A); Personal Rights Form; and the California Seat Belt Safety Laws; and Rotating Food Menu (Week 2). (REFER TO 809C, FOR CONT.)

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

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
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: ANNE CAMPBELL CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 414004898
VISIT DATE: 09/09/2026
NARRATIVE
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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.

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 at this time. 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 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. (REFER TO 809C, FOR CONT.)

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

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
LIC809 (FAS) - (06/04)
Page: 7 of 7
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: ANNE CAMPBELL CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 414004898
VISIT DATE: 09/09/2026
NARRATIVE
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(PAGE 4)
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, deficiencies was observed in the areas evaluated, according to Title 22, Division 12, Chap. 1 Ca. Health and Safety Code of Regulations and cited on LIC809D. An exit interview was completed, including a review of facility evaluation report (FER) and plan of correction, with Assigned Director, Jenny Lam. 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 staff 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: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
LIC809 (FAS) - (06/04)
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