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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005141
Report Date: 10/25/2024
Date Signed: 10/25/2024 11:53:42 AM

Document Has Been Signed on 10/25/2024 11:53 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:GUSTAVSON, DANIELLE R.FACILITY NUMBER:
414005141
ADMINISTRATOR/
DIRECTOR:		GUSTAVSON, DANIELLE R.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 515-9618
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
10/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Danielle R GustavsonTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On October 25th, 2024, at approximately 11:30 AM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced, plan of correction (POC) visit. LPA met with applicant, Danielle R Gustavson, and explained the purpose of the visit. Present during today's visit included applicant only.

On October 17th, 2024, at approximately 3:00 PM, LPA Gil conducted an unannounced, case management inspection. During inspection, licensee was issued one Type A citation for operating as a Large Family Childcare Home without a Child Care license. Present during 10/17/24's inspection , included applicant, assistant, 3 of applicant's children and 8 additional children.

A POC was discussed with applicant. LPA reminded applicant that she must not have any enrolled children in home until licensed by the department. Failure to do this will result in civil penalty, and a potential office meeting.

As of this date, LPA observed applicant to not be operating. During visit, LPA observed 0 children in care.

Deficiencies cited on October 17th, 2024, have been cleared during today's visit. LPA provided licensee with POC letter. No deficiencies were cited today.

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

Exit interview conducted and report was reviewed with licensee, Danielle R Gustavson.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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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