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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005148
Report Date: 05/27/2026
Date Signed: 05/27/2026 11:49:39 AM

Document Has Been Signed on 05/27/2026 11:49 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:AHMADOVA, GULSUMFACILITY NUMBER:
414005148
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
05/27/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:Gulsum AhmadovaTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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On May 27, 2026 @ approx. 9:05 am, Licensing Program Analyst (LPA) Maria Olguin-Leon met with Licensee Gulsum Ahmadova to conduct a POC visit for over capacity in conjunction with a case management visit. LPA explained the purpose of inspection visit to Licensee. Case management visit was for an increase in capacity and to add additional space to daycare areas. Present during visit was Licensee, Licensee’s adult son, and assistant caring for 4 children (3 infants and 1 preschool age). Licensee is operating within capacity limits. All adults living and working in home have criminal background clearances and are associated with facility. Licensee submitted an increase of capacity application to regional office on May 13, 2026. Hours of operation are Monday-Friday 8:00am-6:00pm.

On May 12, 2026, LPA Olguin-Leon met with licensee for a POC inspection visit. During visit, LPA cited Licensee a type “A” deficiency for operating over capacity with 7 children (5 infants and 2 preschool age). POC was developed with licensee.

As of this date, LPA Olguin-Leon confirmed Licensee is in compliance with staff/child ratios and within capacity limits. LPA reviewed children’s roster indicating dates children disenrolled.

During today's visit, LPA observed signed and completed Acknowledgement of Receipt of Licensing Reports (LIC9224) for 5 enrolled children. LPA observed facility site visit and report dated May 12, 2026, posted for parent review.

LPA cleared type A deficiency for overcapacity cited on May 12, 2026, and type B deficiency cited on April 29, 2026, for incomplete children’s files. LPA provided licensee copy of POC clearance letters.

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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2026
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: 05/27/2026
NARRATIVE
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Licensee rents home, which is a tri-level home with 4 bedrooms and 3 bathrooms. LPA and Licensee inspected the indoors and outdoors of home for health and safety hazards. Licensee is requesting to add areas on 2ndlevel floor living to daycare areas, which includes, living room, dining room and kitchen (walk through to dining room) to daycare areas. LPA will approve addition of living room (playroom), dining room and kitchen (walk through).

The Day Care Areas: on first floor living room (main daycare room), bedroom #1 (napping room), bathroom #1, and backyard. Second level includes entrance foyer, living room(playroom), dining room and kitchen (walk through to dining room). The Off-Limits Areas: entire 3rd floor which includes bedroom #2, #3 and #4(master bedroom), bathroom #2, master bathroom #3. LPA observed a child proof retractable gate between entrance foyer and staircase to 3rd floor and a childproof gate on 1st floor to staircase leading to 2nd floor. LPA observed kitchen cabinets secured with childproof latches and two doors at both entrances of kitchen. Living room is secured with childproof gates between entrance foyer and between living room and dining room. LPA observed fireplace in living room(playroom) properly secured for inaccessibility by children. All electrical outlets were secured with childproof covers. Home has proper ventilation and lightening throughout. Home is clean and organized and all cleaning items and potentially harmful items are inaccessible to children and properly stored in childproof cabinets. LPA observed dining room equipped with highchairs and playroom furnished with storage cubbies and age of appropriate toys.

Backyard is properly surrounded by a 5 ft. fence. LPA observed swing/slide play structure, which is secured and anchored to ground, ride-on toys, 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.

LPA observed a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The licensee's CPR and First Aid training is current and will expire 04/2028. The licensee's Mandated reporter training is also current and will expire 07/2026. Per licensee, there are no weapons or firearms in the home.

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

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: 05/27/2026
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Licensee was reminded baby walkers, bouncer, jumpers, and any other similar items are not to be used for children in care.

Capacity limits and ratios for a large family day care have been reviewed with licensee on this date. LPA reminded licensee that an assistant must be present when operating as a large license. LPA reminded licensee when an assistant is not present, licensee must operate as a small license.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

No deficiencies were cited during today’s visit in accordance with title 22.

LPA will approve increase of capacity pending the following:
-Fire inspection clearance and installation of fire alarm

A notice of site visit was given to licensee, Gulsum Ahmadova and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days

Exit interview conducted and report was reviewed with the licensee, Gulsum Ahmadova. Report was translated by Licensee’s son, Musa Huseynzade.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
LIC809 (FAS) - (06/04)
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