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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410509769
Report Date: 06/16/2026
Date Signed: 06/16/2026 01:28:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/23/2026 and conducted by Evaluator Diana Alvarado
COMPLAINT CONTROL NUMBER: 05-CC-20260423144122
FACILITY NAME:CSSF REC DEPT-SIEBECKER CENTERFACILITY NUMBER:
410509769
ADMINISTRATOR:ALENI CAPAZFACILITY TYPE:
850
ADDRESS:510 ELM COURTTELEPHONE:
(650) 875-6979
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:55CENSUS: 36DATE:
06/16/2026
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Site Supervisor, Aleni Capaz, Recreation Community Supervisor, Kimberly Morrison and Supervisor, Diana Gonzalez for Preschool & Early LearningTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Facility did not report unusual incident to department.
INVESTIGATION FINDINGS:
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On June 16, 2026 at approximately at 9:00AM, Licensing Program Analyst (LPA) Alvarado conducted an unannounced, subsequent site visit to the facility to deliver investigation findings in response to the above allegation that was made to the Child Care Licensing Division (CCLD) on April 23, 2026. LPA Alvarado met with Site Supervisor, Aleni Capaz(D1), Recreation Community Supervisor, Kimberly Morrison(S1) and Supervisor, Diana Gonzalez for Preschool & Early Learning(S2). LPA discussed the purpose of the visit. All staff present have Criminal Record Clearance.

During today’s visit, LPA conducted a health and safety inspection indoors and outdoors along with the Facility Representatives (D1), (S1), and (S2). Present during the inspection was (D1) and six staff members supervising thirty-six children Preschool age. Facility is a large classroom that splits into three groups (Jellyfish Moon), (Blue Jays), and (Superhero’s).

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Diana Alvarado
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 05-CC-20260423144122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CSSF REC DEPT-SIEBECKER CENTER
FACILITY NUMBER: 410509769
VISIT DATE: 06/16/2026
NARRATIVE
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During the course of the investigation, LPA conducted classroom observations, gathered documents, and interviewed random selection of staff and Parents. Based on the staff interviews and record review, it was determined that the facility did not report unusual incident to the department that the facility was aware of, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

LPA informed facility representatives (D1), (S1) and (S2) that a Type B deficiency will be cited during today's visit on June 16, 2026.

See LIC9099-D for deficiency cited today regarding reporting requirements. Appeal rights were provided and explained. A notice of site visit was provided and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Facility Representatives, Aleni Capaz, Kimberly Morrison, and Diana Gonzalez.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Diana Alvarado
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 05-CC-20260423144122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CSSF REC DEPT-SIEBECKER CENTER
FACILITY NUMBER: 410509769
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2026
Section Cited
CCR
101212(d)
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101212(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.

This requirement was not met as evidenced by:

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LPA provided the Facility the Regulations 101212 Reporting Requirements, so that the facility can review and understand what protocols need to be taken with reporting requirements. LPA will have the facility submit a written statement, that they understand the reporting requirements and how to prevent a deficiency from occurring again in relation to reporting requirements. Plan will be submitted to LPA Alvarado via email by June 26, 2026.
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Based on interviews and record review the facility did not comply with the reporting requirements as facility did not report an incident that the facility became aware of to the Community care licensing department.
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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.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Diana Alvarado
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
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