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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005199
Report Date: 08/22/2025
Date Signed: 08/22/2025 12:53:19 PM

Document Has Been Signed on 08/22/2025 12:53 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:OLAZABAL, DEYSI MARGARITAFACILITY NUMBER:
414005199
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6TOTAL ENROLLED CHILDREN: 6CENSUS: 3DATE:
08/22/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Licensee, Deysi Margartia OlazabalTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On August 22, 2025 at 10:50am, Licensing Program Analyst (LPA), Tapia-Mandujano conducted an unannounced inspection for the plan of correction (POC) inspection for a Case Management-Licensee Initiated where facility was cited on 8/07/25. LPA met with licensee, Deysi Margarita Olazabal. The purpose of the inspection was explained.

Present in the facility are licensee, assistants, and another adult in the home. All adults present have fingerprint clearance and are associated with the facility. Assistants are supervising two children (1 infant and 1 preschool age). There is also an infant child that is being cared for by their parent in an off limit area. During today’s inspection, the home is operating within license capacity.

On 8/07/25, the facility was cited for two Type A citations during the case management inspection that was conducted to increase capacity from a small to large family child care home license. Licensee did not comply with Title 22 Regulations, Section 102416.5(a) for operating over the maximum capacity of children allowed and Tittle 22 regulations, Section 102370(d) for having an adult present who was not fingerprint cleared and associated.

During today’s inspection, LPA conducted a health and safety inspection of the home. LPA also reviewed the paperwork that was submitted to LPA via email. As well as reviewed children’s files to ensure that the LIC 9224, Acknowledgement of Receipt of Licensing Report were signed and are placed in each child’s file.

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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2025
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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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: OLAZABAL, DEYSI MARGARITA
FACILITY NUMBER: 414005199
VISIT DATE: 08/22/2025
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LPA confirmed children enrolled as of today, there are a total of four children enrolled (2 infants and 2 preschoolers) with two minors in the home that count towards capacity. LPA also verified that adult (A1) that was present in the home is now cleared and associated. LPA observed that the Notice of Site Visit and report documenting a Type A citations are posted on the front door of the home.

Deficiencies cited on 8/07/25 were cleared today.

During today’s inspection, LPA received an updated LIC 279 and LIC 279B with a copy of immunization of tuberculosis of adult living in the home.

The licensee has not obtained a signed Property Owner/Landlord Consent form (LIC 9149). Without this consent, the applicant understands that, they can operate with a maximum capacity of 12 children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 14 children.

Due to clearing the citations and facility being in compliance with capacity limitations as of this day, LPA will approve of a Large Family Child Care Home for maximum capacity of 12 as of today, August 22, 2025.

Based on today's inspection, no deficiencies were observed according the Title 22 Division 12 Ca. Code of Regulations.

Exit interview was conducted and report was discussed with Licensee, Deysi Margarita Olazabal.

This report must be available in the facility for public review. Notice was provided and must remain posted for 30 days. Facility was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov.

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

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC809 (FAS) - (06/04)
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