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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384000668
Report Date: 06/18/2019
Date Signed: 06/18/2019 02:17:14 PM

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:CAI, XIU HUA & LAU, OLIVIA W.FACILITY NUMBER:
384000668
ADMINISTRATOR:CAI, XIU HUA & LAU, OLIVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 203-0598
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:14CENSUS: 10DATE:
06/18/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee, Olivia W. LauTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Cindy Interiano and Winnie Ly, met with Licensee, Olivia W. Lau. Purpose of the inspection was for a case management inspection. Present in the facility is Licensee, Co-Licensee Ms. Cai, and Helper caring for 10 children (4 Infants, 6 PreK).
An inspection of the home was conducted. Home is a two level, 3 bedroom, 2 bathroom house. Daycare Areas are: First level: Daycare area #1 (front of the home), Daycare area #2 (small room), Daycare area #3 (back of the home), small Kitchen, Bathroom #1, and Backyard. Off limit areas are: Entire Second level: Bedroom #1, #2, #3, and Bathroom #2.
Licensee states Fire Inspector conducted a Fire inspection today (06/18/19) and advised Licensee that fire clearance continues to be granted and that all outstanding issues have been resolved.

During the course of an investigation of a complaint, which was being handled by Investigations Bureau (IB) Investigator, Shanie Churchwell, it was determined that:
*IB investigator discovered Licensees having two additional infants in the second level of the home, with a Helper, which is an off limits area.
*Licensee, Ms. Lau was heard telling Helper (in Cantonese) to remain in off limit area of the facility until CCLD inspection was complete.
*Ms. Lau was also heard telling co-Licensee (in Cantonese), Ms. Cai to take another infant to Ms. Cai’s place of residence.
*Ms. Cai disclosed that she does not live in the home and has a different address listed on her California Identification card.

See Page 2. . .
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CAI, XIU HUA & LAU, OLIVIA W.
FACILITY NUMBER: 384000668
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/18/2019
Section Cited
CCR
102416.3(a)(6)
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102416.3(a)(6) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:
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Licensee states she is now making sure the latch on the gate leading to the upstairs level is always placed.

License is being referred to CCL’s Legal Department.
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(6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.
This requirement is not met based on IB Investigator Churchwell’s observation during inspection on 02/21/19 when gate leading to 2nd level of home was unlatched and there were two infants in off limit areas. Also, approved daycare area does not match Facility Sketch on file This poses an immediate safety risk to children in care.
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Type A
06/18/2019
Section Cited
CCR
102416.3(a)(6)
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102417(g)(10)Operation of a Family Child Care Home. A baby walker or similar items are not permitted on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b)&(c).
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Licensees now knows and understands Bouncers are not permitted in licensed Family Child Care homes. Licensees must maintain Bouncers in off limit areas during daycare hours.
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This requirement is not met based on IB Investigator Churchwell’s observation of 4 baby bouncers during inspection on 02/21/19.
Also, during today's (06/18/19) inspection, LPAs observed 2 baby bouncers in the daycare area.
This poses an immediate safety risk to children in care.
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License is being referred to CCL’s Legal Department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CAI, XIU HUA & LAU, OLIVIA W.
FACILITY NUMBER: 384000668
VISIT DATE: 06/18/2019
NARRATIVE
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Page 2. . .

*Licensees were observed having 8 infants and 6 Preschool age children in care at the facility.
*The approved daycare areas do not match the Facility sketch on file.
*The stair gate was unlatched, allowing access to children in care to the second level of the home.
*IB investigator observed 4 baby bouncers in the facility.

This License will be referred to CCL’s Legal Department.

>See deficiencies cited today under Title 22 Division 12 of the Ca. Code of Regulations.

Type ‘A’ deficiency has been issued. Deficiency and Acknowledgment of Receipt of Licensing Reports (LIC 9224) must be given to all Guardians (current and new/incoming Families for the next 12 months) for all Guardians to sign and return. Signed form must be in child's folder.

>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CAI, XIU HUA & LAU, OLIVIA W.
FACILITY NUMBER: 384000668
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2019
Section Cited
CCR
102352(h)(1)
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102352 Definitions
(h) (1) "Home" means the licensee's residence as defined by Government Code Section 244.

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License is being referred to CCL’s Legal Department.
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This requirement is not met based on Co-Licensee, Ms. Cai disclosing that she does not live in the home full time and has a different address listed on her California Identification card.
This poses an immediate safety risk to children in care.
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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.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CAI, XIU HUA & LAU, OLIVIA W.
FACILITY NUMBER: 384000668
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/18/2019
Section Cited
HSC
1596.885(c)
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HSC 1596.885(c) Conduct Inimical: Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state.
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License is being referred to CCL’s Legal Department.
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Licensees asked Helper in Cantonese to keep infants in off limit areas until CCLD leaves facility. Licensee was also overheard asking Co-Licensee to take infant to her other place of residence.
This requirement is not met based on IB Investigator Churchwell’s observation during inspection on 02/21/19. This poses an immediate safety risk to children in care.
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Request Denied
Type A
06/18/2019
Section Cited
CCR
102416.5(a)
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102416.5(a) Staffing Ratio and Capacity. The capacity specified on the license shall be the maximum number of children for whom care can be provided.
This requirement was not met as
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Max capacity for a Large Family Child Care Home is: MAX of 12 children-combo of up to 4 infants (under 24 mo) and 8 PreK (over 24 mo) OR MAX of 14 children-combo of up to 3 infants, 8 PreK, and 2
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evidence based on IB Investigator Churchwell’s observation of 8 infants and 6 PreK age children during inspection on 02/21/19. This poses an immediate safety risk to children in care.
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School Age (Kinder+ & 1st grade+).
During inspection today (6/18/19), there were 10 children present (4 infants, 6 PreK).
License is being referred to CCL’s Legal Department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5