<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376626750
Report Date: 08/18/2021
Date Signed: 08/18/2021 03:50:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:ZHANG, LI FAMILY CHILD CAREFACILITY NUMBER:
376626750
ADMINISTRATOR:LI ZHANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 692-5861
CITY:SAN DIEGOSTATE: CAZIP CODE:
92131
CAPACITY:14CENSUS: 5DATE:
08/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Li ZhangTIME COMPLETED:
04:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/18/2021 at 2:05am, Licensing Program Analyst (LPA) Samantha Clenista and Patrick Ma visited the facility to conduct an unannounced case management site inspection. Upon arrival, LPA's met with Li Zhang (Licensee), and proceeded to tour the facility. There were 5 children in care who were all observed napping, 2 who are infants. Also present was Jiangbi Li, Helper. Appropriate ratio and capacity was observed during time of inspection. The purpose of this visit is to follow up on an unusual incident regarding a child sustaining unexplained bruising (unknown if it occurred at the facility). Incident was self-reported by Licensee on 06/18/2021. The original follow-up took place on 6/21/2021 by LPA Ma via phone. Outside agency reports and other related documentation was obtained and reviewed since the original incident occurred. During inspection, LPA Ma interviewed Licensee and obtained additional related documentation.

All required notices, forms and licenses were posted. Furniture and age appropriate equipment is in good condition. Rooms have adequate heating, lighting, and ventilation. Children’s personnel and facility records were reviewed. Forms/records to keep in your FCCH (LIC311D), YMCA Smart Start Resource Packet, PIN 20-24 and Appeal Rights (1/16) was provided and reviewed with Licensee.

No deficiencies were cited today. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA's observed Licensee post notice of site visit. LPA's reviewed this report with Licensee prior to obtaining her signature.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Samantha ClenistaTELEPHONE: (619) 818-6740
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1