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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503488
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:26:33 PM

Document Has Been Signed on 10/23/2024 03:26 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:SMITH, SHIRELFACILITY NUMBER:
380503488
ADMINISTRATOR/
DIRECTOR:		SMITH, SHIRELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 846-8488
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
10/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:06 PM
MET WITH:Carmen SmithTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On October 23, 2024 at approximately 2:45pm, Licensing Program Analyst (LPA) Tso conducted an unannounced, annual visit to the Family Child Care Home listed above. The LPA was granted entry by the Licensee’s daughter, Carmen Smith. LPA explained the purpose of the visit. Present during LPA's visit included licensee's daughter, and 0 children.

Per the licensee’s daughter, there is personal issue of the licensee that the facility was closed since 7/25/2024. LPA observed that the facility was almost clean up. Per the daughter of the licensee, she wants to put the child care license status in active for a year. The Request for Inactive Child Care Status (LIC9211) was signed by the licensee’s daughter on behavior.

There were no deficiencies cited at this time under CCR, Title 22, Div. 12. A copy of today’s report was given to the licensee.

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

Exit interview conducted and report was reviewed with the licensee, Carmen Smith.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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