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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005141
Report Date: 10/17/2024
Date Signed: 10/17/2024 04:19:21 PM

Document Has Been Signed on 10/17/2024 04:19 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: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: 8DATE:
10/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Danielle R. GustavsonTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 10/17/2024, at approximately 3:00 PM Licensing Program Analyst (LPA), Janet Gil, conducted an unannounced case management visit to address 280 Angelita Ave in Pacifica. Applicant allowed LPA in the home for inspection. LPA met with applicant Danielle R. Gustavson. Purpose of the visit was to contact applicant regarding scheduling a pre-licensing visit. LPA has left multiple messages and a letter to applicant regarding this inspection, however has not herd back.

Present during inspection , included applicant, assistant, 3 of applicant's children and 8 additional children. Per applicant, she lives in the home with her three children. Applicant is operating as a Large Family Childcare Home without a Child Care license. LPA informed applicant that she can only provide care for her own children, along with an additional child without a license. Per applicant, she has reached out to fire for an inspection for the following week. Per applicant, she has not reached out to LPA due to having other personal commitments.

Prior to operating applicant must,

- Receive Guardian fingerprint clearance for self, and assistant
- Fire Clearance for a Large License
- A Pre-licensing Visit where she is approved by LPA to have Child Care License (visit has been scheduled for 10/24/2024 at 9 AM

LPA reminded applicant that she must not have any enrolled children at time of inspection, and can only have children until licensed. Failure to do this will result in civil penalty, and a potential office meeting.

See LIC9099-D for Type A deficiency cited today. Appeal rights were provided to applicant.

A copy of today's report and appeal rights were given to Danielle R. Gustavson.

Exit interview conducted and report was reviewed with Danielle R. Gustavson
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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Document Has Been Signed on 10/17/2024 04:19 PM - It Cannot Be Edited


Created By: Janet Gil On 10/17/2024 at 03:57 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: GUSTAVSON, DANIELLE R.
FACILITY NUMBER: 414005141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2024
Section Cited
CCR
102357

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CCR 102357 Operation Without a License.
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Facility administrator will stop all operation untill licensed by LPA Gil.

LPA will scheduale fire clearance for following week and complete fingerprint clearance for self and assistant.

Possible office meeting will be scheduled if still operating without regulation compliances.
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Based on observation and interview with the applicant, LPA Gil confirmed that the residential home is operating without a state regulated license which poses an immediate health, safety or personal rights risk to persons in care.
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Civil penalties may be assessed.

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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: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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