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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004808
Report Date: 08/25/2026
Date Signed: 08/25/2026 11:59:22 AM

Document Has Been Signed on 08/25/2026 11:59 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:MARTINEZ SEGOVIA, ANDRESFACILITY NUMBER:
384004808
ADMINISTRATOR/
DIRECTOR:		MARTINEZ SEGOVIA, ANDRESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 894-7908
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
08/25/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Alba Velasquez, Andres Martinez SegoviaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 8/25/2026 at 9:10AM., Licensing Program Analyst (LPA), Luis Gomez met with Assistant, Alba Velasquez. The purpose of today’s visit was explained and was for an unannounced, annual/ random inspection. The licensee, Andres Martinez Segovia arrived to visit during inspection. Present was the licensee and 2 assistants caring for 9 children (4 infant-age, 5 preschool -age). All adults have criminal record clearances on file. The licensee's home is a 4 bedroom, 3 bathroom, 1 level unit. The days and hours of operations are: Monday- Friday, 8:00AM.- 5:00PM. The area of the home designated for childcare are: Bedroom #1 (Playroom #1), Bedroom #2 (Napping Only), Bathroom #1, Bathroom #2, Kitchen, Living Room (Lunch Area/ Playroom #2). The areas of the home designated as off limits are: Bathroom #3; Bedroom #3, Bedroom #4, and Backyard. LPA inspected home with licensee for health and safety hazards.

At 9:15AM., The following was observed: Facility clean and neat with age-appropriate playthings/ materials available for the children. All floors and ground surfaces were clear of obstructions or hazards. The furniture and playthings inspected were in good repair and anchored.

LPA reminded licensee to installed covering or removed sharp cornered furniture in playroom. Advisory Note: Technical Violation (LIC9102TV).

The bathroom was observed clean with adequate supplies for handwashing. LPA observed a changing table available for the staff to use as needed.

The playroom has several chairs and table, scaled to the appropriate size. The off-limits areas have been made inaccessible with child safety gates and doors. For napping services/ scheduled rest, LPA observed several cots and cribs in facility. Per licensee, linens and blankets are washed once per week by facility.

The home was maintained at a comfortable temperature, was well-lit, and had sufficient ventilation. The facility was equipped with a telephone service (cell phone); functioning smoke detector/ carbon monoxide combination detector; and fully charged- fire extinguisher (4A80BC) in kitchen. (REFER TO 809C, FOR CONT.)

Marie Rodriguez
Luis Gomez
DATE: 08/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2026
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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Document Has Been Signed on 08/25/2026 11:59 AM - It Cannot Be Edited


Created By: Luis Gomez On 08/25/2026 at 10:46 AM
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: MARTINEZ SEGOVIA, ANDRES
FACILITY NUMBER: 384004808

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 9:55AM., Based on record review, LPA confirmed Licensee's CPR/1st aid certification was expired. This poses a potential risk to the health and safety of children in care.
POC Due Date: 09/23/2026
Plan of Correction
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The licensee will renew required cardiopulmonary resuscitation (CRP) / pediatric first aid certification by the due date: 9/23/2026. Proof of correction will be submitted to the Department via email.
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:
Luis Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2026


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: MARTINEZ SEGOVIA, ANDRES
FACILITY NUMBER: 384004808
VISIT DATE: 08/25/2026
NARRATIVE
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(Page 2)
The home did not have pools, ponds, or other bodies of water on the premise.

During inspection, LPA reviewed facility records including the 9 children’s files and 2 personnel files. The staff files were reviewed and included the: Proof of Immunization; Notice of Employee Rights (LIC9052); and proof of completed mandated reporter training course, AB1207.

The children’s files were reviewed and included the: Identification and Emergency Information (LIC700); Immunization records; and Notice of Additional Children in Care (LIC9150).

LPA reviewed random sample documentation of 15 minute review of infant napping conditions. The documentation included child’s: name, date, and time.

At 9:55AM., Based on record review, LPA confirmed Licensee's CPR/1st aid certification was expired.
The licensee’s proof of the completed mandated reporter training course (AB1207) was on file, and expires: 6/3/2028.

Per licensee, facility conducts the required emergency disaster drills (fire and earthquake) every 6 months, with last drill done on, 8/24/2026.

The required forms are posted in entry way and include Facility License Certificate; Notification of Parent’s Rights (PUB379) and Emergency Disaster Plan (LIC610A).
Per license, isolation of an ill child is in the infant. Per licensee, the guardians provides daily breakfast, snack and lunch for children in care. (REFER TO 809C, FOR CONT.)
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026
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: MARTINEZ SEGOVIA, ANDRES
FACILITY NUMBER: 384004808
VISIT DATE: 08/25/2026
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The licensee was reminded that all adults 18 years and over living in the home, person who provides care and supervision to children, and staff who have contact with children, including employee and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain criminal 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.

The LPA discussed safe sleep regulations with licensee and the Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
Facility was informed of the www.mychildcareplan.org site is a consumer education website that helps families obtain child care by connecting to child care providers and resources and referral agencies (R&R) throughout California.
Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 20-02-CCP. When an IMS is provided, a plan for 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- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
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 tool, please send them to [email protected]. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesource/community-care-licensing/inspection-process.

Based on today's inspection, deficiencies were observed in areas evaluated according to California Title 22, Div. 12 Chap. 3, Health and Safety Code of Regulation and cited on LIC809D. The exit interview, including the facility evaluation report, and plans for correction was discussed with Licensee, Andres Martinez Segovia. The licensee’s signature on this form acknowledges receipt of these documents.

During exit interview, licensee confirmed no registered sex offenders are living in the home, and RSO profile was completed by LPA. The notice of site visit must remain posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026
LIC809 (FAS) - (06/04)
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