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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005040
Report Date: 06/27/2025
Date Signed: 06/27/2025 12:31:01 PM

Document Has Been Signed on 06/27/2025 12:31 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:GONZALEZ LOPEZ, ELVI C.FACILITY NUMBER:
414005040
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 3CENSUS: 3DATE:
06/27/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Licensee, Elvi Gonzalez LopezTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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On June 27th, 2025, at approximately 8:45am, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced random/annual and Case Management-Licensee initiated inspection. LPA met with licensee, Elvi Gonzalez Lopez. LPA explained the purpose of the inspection to licensee. Present in the facility are licensee supervising three infant children. During today's inspection, all adults living and/or working in the facility are fingerprint cleared and associated.

Licensee has requested to increase capacity from a Small Family Child Care Home to a Large Family Child Care Home. Capacity limitations were explained. Copy of Capacity worksheet was left with licensee as an additional Resource. Licensee has also requested to add Bedroom #1 and side yard as part of a daycare area. Redwood City Fire Department has granted fire clearance on June 9th, 2025. LPA inspected Bedroom #1 for health and safety hazards. Bedroom #1 was observed to be free of any hazards, outlet covers have safety covers, and no immediate dangers were observed. Per licensee, Bedroom #1 primary use will be for sleeping. Side yard is added due to it being the emergency exit. LPA observed the side yard have some items that can be hazardous and items blocking the exit. Per licensee, she will clear the side yard and make it free of any hazards and clear from blocking the exit. Once that is cleared, LPA can approve the side yard. LPA will approve Bedroom #1 to be added as a daycare area.



Licensee rents a two bedroom one bathroom single story home with garage and backyard. Licensee lives with adult husband and three minor children. The hours of operation are Monday-Friday from 8am-5:30pm. Daycare areas are: Living Room, Dining Room, Bedroom #1, Bedroom #2, Bathroom, and backyard. OFF limit areas are: Kitchen, Garage, Front yard/Driveway. All off limit areas are properly barricaded, including all closets.

LPA observed the Day-care is clean, orderly with a variety of age-appropriate toys for the children. All furniture inspected is in good repair. The licensee has a fully stocked First Aid kit and was reminded to be aware of the expiration on the First Aid Kit. Home does not have any pools or bodies of water. LPA reminded licensee about water safety. Per licensee, there are no pets in the home. The home does not have a fireplace, ope face heather are properly barricaded. The home has age-appropriate equipment available for children in are. Licensee was reminded that baby walkers, bouncers, jumpers, and any other similar items are to not be used for children in care.

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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2025
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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Document Has Been Signed on 06/27/2025 12:31 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 06/27/2025 at 11:24 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: GONZALEZ LOPEZ, ELVI C.
FACILITY NUMBER: 414005040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as licensee's CPR & FIrst AId certificate has expired April 2025. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Per licensee, she has registed for a training but will attempt to find one sooner.

Licensee will submit proof to LPA Tapia-Mandujano of proof of enrollement for CPR & FIrst Aid training via email by 7/25/25. Once training is complete, licensee will submit proof of the certificate.
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:
Leslit Tapia-Mandujano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


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: GONZALEZ LOPEZ, ELVI C.
FACILITY NUMBER: 414005040
VISIT DATE: 06/27/2025
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Per licensee, infant children currently sleep in Bedroom #2 in pack and plays. LPA observed that pack and plays are free of any loose articles or objects. LPA observed that licensee is maintaining safe sleep logs. Discipline policy was discussed. Isolation area for sick child will be in bedroom #2. Per licensee, she has not conducted an emergency drill in the last six months, Techinical Violation was received. Licensee agress to conduct emergency drills at least once every six months and log drills. Licensee's CPR & First Aid expire on 04/2025, Deficiency was received. Licensee's Mandated Reporter Training Certificate will expire on 05/2027.

There was a fully charged fire extinguisher and a smoke and carbon monoxide alarm, and a working telephone. Phone number listed for Licensee is current. Per Licensee, there are no weapons or firearms in the home. LPA reviewed four child’s records and employee records. Licensee's Mandated reporter training expires on 04/2026. Licensee’s Pediatric CPR/First Aid Certification expires 04/25/25. Per licensee, she will renew her certification over the weekend. Last Emergency drill was conducted 01/2025. Emergency drills must be conducted at least once every six months and must be properly logged.

LPAs observed that all the required posting documentation, such as the facility license, Notification of Parental Rights were posted in a prominent area for parents or representatives to review. Discipline Policy was also discussed.

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 atwww.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

Licensee 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 Family Child Care Home. 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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
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: GONZALEZ LOPEZ, ELVI C.
FACILITY NUMBER: 414005040
VISIT DATE: 06/27/2025
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Incidental Medical Services (IMS) policy was discussed. Licensee does not offer IMS at this moment. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing 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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee 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.

During the exit interview, the licensee, Elvi Gonzalez Lopez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 6/27/2025.

Deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

A notice of site visit was given and must remain posted for 30 days.

Large Family Child Care Home license has been approved as of today, June 27, 2025.

Exit interview was conducted and report was reviewed with Licensee, Elvi Gonzalez Lopez, and copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
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