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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421741
Report Date: 10/30/2019
Date Signed: 10/30/2019 10:01:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:LIN, YANGJINFACILITY NUMBER:
013421741
ADMINISTRATOR:LIN, YANGJINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 308-6706
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:14CENSUS: 5DATE:
10/30/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Yangjin LinTIME COMPLETED:
10:10 AM
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LPAs Mayla Mendoza and Elimika Woods met with licensee for a plan of correction visit to clear the deficiencies cited on 10/22/19 complaint visit. Present for the visit were licensee's husband and 4 infants and 1 preschool child in care. The following corrections have been made:

1) 102416.5(e)--licensee has an assistant present today


As a result of this visit, there are no deficiencies cited.

An exit interview was conducted.

A notice of site visit was posted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2019
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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