384000808-11-19-2019-05-CC-WLYY-BJ3QDM-20191119110455

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384000808
Report Date: 11/19/2019
Date Signed: 11/19/2019 11:05:04 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:	MOY, XIAO-SONG		FACILITY NUMBER:	384000808
ADMINISTRATOR:	MOY, XIAO-SONG		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 664-3977
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94116
CAPACITY:	14	CENSUS: 11	DATE:	11/19/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Xiao-Song Moy		TIME COMPLETED:	11:15 AM

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 November 19, 2019, at approximately 9:00am, Licensing Program Analyst (LPA) Winnie Ly conducted an annual unannounced visit to this family child care home and met with Licensee Xiao-Song Moy. Purpose of visit was explained. Present during the visit were Licensee, helper and 6 children. It is a two level single family house. Licensee owns the house. Licensee lives here with her husband and her adult daughter. Day Care Areas are on the ground floor which consisted of a big play room, nap room, kitchen/dining, bathroom and backyard. Off Limit Areas are the entire second floor and the garage. Licensee’s CPR expires 04/14/2021. Completed Child Abuse Mandated Reporter Training Certificate is on file. Required Immunization Influenza, Pertussis and Measles are on file. LPA observed the home is clean orderly and properly ventilated. LPA also observed a 2A10BC Fire extinguisher, operable smoke detector and carbon monoxide. There are no Fireplace or bodies of water in the home. Electrical outlets have child protective covers in place making them inaccessible to children. Chemical, detergents, cleaning compounds, medications, and other items of this nature are made inaccessible to children. Kitchen/Bathroom cabinets/drawers have child protective locks in place making all sharp objects or toxic house hold items inaccessible to children. First aid supplies are available for children. Facility conducts fire drills/earthquake drills on 09/27/2019 and was properly logged. If there was an ill child, staff would separate the child from the group while waiting for parent to pick them up. Disciplinary policy was discussed with Licensee today. Home has age appropriate toys and equipment available for the children in care. LPA reviewed children's and staff’s files today. All Files are up to date. All required posting documents are posted and visible. CONTINUED>>>

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie Ly	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

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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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: MOY, XIAO-SONG	FACILITY NUMBER: 384000808
	VISIT DATE: 11/19/2019

NARRATIVE

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This family child care home does not provide Incidental medical Services to children in care. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

Licensee was also informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. All staff have proof of Immunization.

LPA discussed Child Abuse Mandated Reporter Training AB1207 with Licensee. As of January 1, 2018 all staff will be required to complete Child Abuse Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

No deficiencies were issued today under Title 22 Division 12 of the Ca. Code of Regulations. Notice of Site Visit was posted. Notice to remain posted for 30 days. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie Ly	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

LIC809 (FAS) - (06/04)

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