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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380505442
Report Date: 08/14/2019
Date Signed: 08/14/2019 11:11:13 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:NG, JEANNE - JEANNE FAMILY DAY CAREFACILITY NUMBER:
380505442
ADMINISTRATOR:NG, JEANNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 586-6871
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:12CENSUS: 10DATE:
08/14/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jeanne Ng, AiYu Lin, Queenie LeeTIME COMPLETED:
11:30 AM
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Licensing Program Analyst, LPA conducted a case management inspection today. There are 10 children, licensee, Jeanne, and 2 helpers present today. The facility requested to add a co-licensee Queenie Lee on to her license. Today, LPA inspected the home. The following is needed.

1) Upper-level sketch
2) LIC279
3) CPR,1st aid, 8 hr of Health and Safety for Queenie Lee
4) Lease agreement
5) Child Abuse Mandated Reporter Training, AB1207. https://www.mandatedreporterca.com/ for Queenie Lee
6) Orientation certificate
7) Immunization (TB, influenza, pertussis, and measles)
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
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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