384000808-12-15-2023-05-CC-BVAN-CYJRT9-20231215121758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384000808
Report Date: 12/15/2023
Date Signed: 12/15/2023 12:18:05 PM

Document Has Been Signed on 12/15/2023 12:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 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: 12	DATE:	12/15/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Xiao-Song Moy		TIME COMPLETED:	12:15 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 December 15, 2023., Licensing Program Analyst (LPA) Van performed an annual required inspection, which included checking the interior and exterior of the facility and discussing the required childcare paperwork with the Licensee. LPA met with the Licensee’s helper, Li Nu. The Licensee came home during the inspection. Licensee, Xiao-Song Moy and two helpers supervised 12 preschool-age children. Children's capacity and ratio criteria were seen to be satisfied today. The Childcare areas are on the ground floor, consisting of a big playroom, nap room, kitchen, two bathrooms, and 1/2 of the backyard. The off-limit areas are the entire second floor, the garage, and the back half of the backyard, including the storage shed. All restricted daycare areas have been appropriately blocked off from the children. Days and operations are from Monday through Friday, from 7:30 am to 5:30 pm. The Licensee has valid childcare liability insurance through DC Insurance Services. LPA inspected the facility's indoor and outdoor environments for health and safety purposes. The childcare area is clean and organized, with age-appropriate toys and equipment. The house has sufficient lighting and ventilation. A functional telephone, a working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher are all present in the house. According to the Licensee, no bodies of water are on the premises. Daycare children have no access to detergents, disinfectants, or cleaning chemicals. The Licensee claims there are no guns or weapons in the house. Continued on page 2...

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MOY, XIAO-SONG	FACILITY NUMBER: 384000808
	VISIT DATE: 12/15/2023

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
26
27
28
29
30
31
32

LPA reviewed and discussed the Safe Sleep Regulation with the Licensee. The Licensee was reminded by LPA of specific guidelines that must be followed when it comes to playpens and cribs. Specifically, it is advised not to keep toys, blankets, or pillows inside or any objects hanging above the cribs/playpens. The mattresses should be designed specifically for the cribs/playpens, and bed sheets must be tightly fitted. LPA also informed the Licensee that checking on the infant every 15 minutes during naptime is mandatory. It is necessary to document these checks and keep them in the infant's file for review by the Department.

The outdoor area is fully enclosed with a fence and has a climbing and sliding structure in the middle. Soft rubber cushions have been installed beneath the equipment to ensure safety and prevent accidental falls.

The Licensee's and helpers' CPR and First Aid certifications are valid. Emergency drills are held every other month, with the most recent drills completed on 11/21/23. The drills log was reviewed and found completed. All staff members maintained complete immunization records and had valid mandated reporter training certificates.

Children's files were reviewed. The Licensee maintains thorough records for all children in their care, including vaccination records and Parental Rights forms. LPA noted that each kid had a complete emergency information card that included the child's full name, phone number, and the location of a parent or authorized person who may be called in an emergency. LPA discussed care and supervision with the Licensee. There is no transportation provided. Capacity options were reviewed, and the Licensee acknowledges that care cannot be provided over the capacity specified on the license. The requirements for reporting suspected child abuse, as well as reporting requirements for unusual incidents, were discussed. All mandatory postings (License/Parent's Rights poster/Emergency Disaster Plan and Earthquake Preparedness Checklist) are posted.
Continued on page 3...

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MOY, XIAO-SONG	FACILITY NUMBER: 384000808
	VISIT DATE: 12/15/2023

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
26
27
28
29
30
31
32

The Licensee serves lunch and pm snacks. The discipline used is redirection. Isolation of ill children was reviewed and discussed.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with the Licensees and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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: www.ada.gov/childqanda.htm.

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare 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.
Continued on page 4...

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MOY, XIAO-SONG	FACILITY NUMBER: 384000808
	VISIT DATE: 12/15/2023

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
26
27
28
29
30
31
32

LPA reviewed AB 1207 with the Licensees. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. Effective July 1, 2020, Licensees must have proof of completion of EMSA certified lead poison training if applying for a change of location or capacity change to an existing license.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE, XIAO-SONG MOY, confirmed that there are no Registered Sex Offenders living in the facility, and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted, and the report was reviewed with the licensee, Xiao-Song Moy.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4