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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005148
Report Date: 04/29/2026
Date Signed: 04/29/2026 02:55:44 PM

Document Has Been Signed on 04/29/2026 02:55 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:AHMADOVA, GULSUMFACILITY NUMBER:
414005148
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
04/29/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Gulsum AhmadovaTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On April 29, 2026, at approximately 9:15 am, Licensing Program Analyst (LPA) Maria Olguin-Leon met with licensee, Gulsum Ahmadova to conduct an unannounced annual inspection. The purpose of the inspection visit was explained to Licensee. Present during today’s visit was licensee, licensee adult daughter and an assistant, caring for 6 children (1 infant and 5 preschooler). Licensee is following ratio capacity requirements during LPA’s visit. At approx. 9:25 am, LPA observed assistant (A1) with no criminal background clearance, which poses an immediate risk to children in care. A type “A” citation was issued today for this deficiency. Childcare hours of operation are Monday - Friday from 8:00 am to 5:30 pm.

LPA observed Childcare License, Emergency Disaster Plan (LIC610A), Earthquake Preparedness checklist, and Parent's rights posted at entrance of home. Per Licensee, last emergency drill was conducted February 2026. LPA reminded licensee to properly document emergency drills with date, time and number of children present and conduct drills every 6 months.

LPA observed a fully charged fire extinguisher stored in cabinet in main playroom. LPA reminded Licensee to have fire extinguisher easily accessible. Licensee maintains fully stocked first aid kits. Smoke detector and carbon monoxide detector were both tested during today’s visit and observed to be in working condition. LPA reminded Licensee to keep carbon monoxide always plug in. Licensee maintains a personal cell phone and cell phone dedicated to daycare on the premises. Per Licensee, there are no weapons or firearms in the home.

LPA inspected the indoors and outdoors of home for health and safety hazards. LPA observed home to be free of defects or conditions that might endanger a child. Home is a tri-level home with 4 bedrooms and 3 bathrooms. Licensed Daycare areas are: Entrance foyer/hall, lower lever- main playroom, bedroom #1 (napping room), bathroom #1, and backyard. Off-limit areas are: Entire 3rd floor, living room, dining room, kitchen and garage. Isolation area: Sick children will be isolated in lower-level hallway area and away from other children. LPA observed children seated in highchairs in dining room area and living being used as a daycare area, which poses a potential risk to children in care. A type “B” citation was issued today for this deficiency. LPA advised Licensee to submit an updated application and facility sketch to add new areas for daycare use. The home has proper heating, lighting and ventilation to provide safety and comfort. LPA observed child-size furniture, storage cubbies, books, learning material and other age-appropriate toys, all in good condition.

Cont. page 2...
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2026
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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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: AHMADOVA, GULSUM
FACILITY NUMBER: 414005148
VISIT DATE: 04/29/2026
NARRATIVE
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Fireplace in off limits living room is barricaded and covered with thick cardboard and dry erase board to prevent access to children. Staircase from entrance foyer to third floor is secured with a retractable childproof gate and staircase from lower-level floor to entrance foyer is secured with a childproof gate. LPA observed both entrances into living room secured with childproof gates. Electrical outlets are secured with childproof covers and barricaded with furniture. LPA observed flooring in daycare rooms to have rugs to absorb and cushion falls.

Bathroom was clean and cabinets were secured with childproof latches. Bathroom is equipped with a stepping stool and potty-training chairs. LPA observed a changing table in main playroom with a diaper changing foam mat. Cabinet next to changing table is equipped with children’s diapering supplies. Cleaning supplies and other potentially harmful items are stored inaccessible to children and behind child proof cabinets.

LPA observed a crib and toddler size beds in bedroom #1 for napping purposes. Main playroom also had a crib and toddler size bed. Cribs and bed mattresses were firm and covered with tight fitting sheets. Cribs were free of loose articles, objects and blankets. Licensee provides sheets for mattresses and washing sheets on a weekly basis or as needed. Infant 15-minute sleep logs were unavailable for LPA to review, which poses a potential risk to children in care. A type “B” citation was issued today for this deficiency.

Backyard is enclosed and surrounded with a 5 ft wood fence. All off limits areas of backyard are secured with plastic child proof gates. LPA observed a slide swing play structure securely anchored to ground, ride-on toys, small slide, child size table and other age-appropriate toys, all in good condition. Flooring in backyard is cement and artificial grass to cushion falls. Backyard is equipped with a gazebo and umbrellas to provide shade for children in care. LPA did not observe any pool, spas, or other bodies of water.

Licensee provides meals for children in care, which includes breakfast, lunch, dinner and am/pm snack. LPA reminded licensee that any food brought from home must be labeled and stored properly. LPA observed several highchairs in off limits dining room and child size table and chairs for child to sit and eat. LPA observed food properly stored in kitchen to avoid contamination or spoilage. Kitchen cabinets were secured with child proof latches.

Cont. page 3...
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
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: AHMADOVA, GULSUM
FACILITY NUMBER: 414005148
VISIT DATE: 04/29/2026
NARRATIVE
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Children’s files were not available for LPA to review, as this poses a potential risk to children in care, a Type ‘B” citation was issued today for this deficiency. Children’s roster is maintained electronically, LPA provided Licensee with LIC9040 (Children’s roster). Licensee’s CPR/FA expiration date is 4/2028 and licensee’s Mandated reporter ex. 7/2026. LPA provided Licensee with PM286 to record and update children's vaccines.

Licensee Gulsum Ahmadova was reminded that all adults 18 and over living or working in the home, 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 licensed 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 Gulsum Ahmadova 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 [or facility representative] of the importance of checking for and removing any 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.

As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. LPA reminded licensee about Mandated Reporter training available www.mandatedreporterca.com

Incidental Medical Services (IMS) policy was discussed. 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 Gulsum Ahmadova 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.

Cont. page 4...
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
LIC809 (FAS) - (06/04)
Page: 4 of 9
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: AHMADOVA, GULSUM
FACILITY NUMBER: 414005148
VISIT DATE: 04/29/2026
NARRATIVE
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Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA reviewed AB 1207 with the Licensee.

During the exit interview, the Licensee Gulsum Ahmadova, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

See page LIC809D for deficiencies issued during today’s visit, under CCR, Title 22, Division 12.

LPA Maria Olguin-Leon informed licensee Gulsum Ahmadova that this report dated April 29, 2026, document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Maria Olguin-Leon informed the licensee Gulsum Ahmadova to provide a copy of this licensing report dated April 29, 2026 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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

Exit interview conducted and report was reviewed with the licensee, Gulsum Ahmadova. Report was translated by Musa Huseynzade (licensee son) and Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2026 02:55 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 04/29/2026 at 12:54 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: AHMADOVA, GULSUM
FACILITY NUMBER: 414005148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in LPA observed an assistant (A1) working with children without criminal background clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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LPA provided A1 with LIC9163 and A1 left facility to complete criminal background clearance. Licensee understands A1 must have criminal background clearance before returning to work in home.
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:
Maria Olguin-Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 04/29/2026 02:55 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 04/29/2026 at 12:54 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: AHMADOVA, GULSUM
FACILITY NUMBER: 414005148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in 15 minute sleep logs were not maintained for enrolled infant.


[count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2026
Plan of Correction
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Licensee will maintain 15 minute sleep logs for enrolled infant and will have sleep logs available for LPA to review by POC due date.
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in off limits areas (living room & dining room) were being used for daycare purposes, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2026
Plan of Correction
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Licensee will submit an updated application to Regional office for increase of capacity and update daycare areas to include current off limits areas.
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:
Maria Olguin-Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2026 02:55 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 04/29/2026 at 12:54 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: AHMADOVA, GULSUM
FACILITY NUMBER: 414005148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 5 out of 5 children did not files available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2026
Plan of Correction
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Per Licensee, files were maintained electronically and unable to access. Licensee will print and maintain hardcopy of all required licensing forms in files and will keep files in home.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:
Maria Olguin-Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2026


LIC809 (FAS) - (06/04)
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